Electrode designs in implantable defibrillator systems

ABSTRACT

A subcutaneous implantable cardioverter-defibrillator (S-ICD) comprising shocking electrodes configured to reduce the defibrillation threshold. The S-ICD may include a canister housing a source of electrical energy, a capacitor, and operational circuitry that senses heart rhythms and an electrode and lead assembly. The electrode and lead assembly may comprise a lead, at least one sensing electrode, and at least one shocking electrode. The at least one shocking electrode may extend over a length in the range of 50 to 110 millimeters and a width in the range of 1 to 40 millimeters.

CROSS-REFERENCE TO RELATED PATENT DOCUMENTS

The present application claims the benefit of and priority to U.S.Provisional Patent Application Ser. No. 62/331,737, filed on May 4,2016, and titled ELECTRODE DESIGNS IN IMPLANTABLE DEFIBRILLATOR SYSTEMSand to U.S. Provisional Patent Application Ser. No. 62/344,042, filed onJun. 1, 2016, and titled ELECTRODE DESIGNS IN IMPLANTABLE DEFIBRILLATORSYSTEMS the disclosures of which are incorporated herein by reference.The present application is related to U.S. Provisional Application Ser.No. 62/331,721 filed on May 4, 2016 and titled DELIVERY TOOLS INIMPLANTABLE DEFIBRILLATOR SYSTEMS, the disclosure of which isincorporated herein by reference.

BACKGROUND

The S-ICD System™ from Cameron Health, Inc., and Boston ScientificCorporation presents a new opportunity in cardiac rhythm management toreduce the complications associated with transvenous defibrillatorsystems. The defibrillator system itself may be implanted subcutaneouslywithout accessing the vasculature or touching the heart.

The first approved commercial version of the S-ICD System™ deliveredapproximately 80 Joules of energy for defibrillation therapy. To supplythis amount of energy in a timely fashion over the life of the device,three high power capacitors and three batteries were used in the firstapproved S-ICD System™ devices. Enhancements to reduce the total energyrequired may allow for reduction in size by facilitating the use ofsmaller or fewer batteries and/or capacitors. In addition, it is desiredto increase the already high likelihood of successful implantation asmeasured by the ability to convert induced ventricular fibrillation atimplant using 65 Joule therapy (an imputed success rate of 96.5% wascalculated in PMA P11042: FDA Summary of Safety and Effectiveness Data,available online athttp://www.accessdata.fda.gov/cdrh_docs/pdf11/P110042b.pdf). New andalternative defibrillation lead and electrode designs, as well asalternative implant tools and methods, may be useful to achieve thesegoals.

OVERVIEW

The present inventors have recognized, among other things, that aproblem to be solved is the provision of new and different lead designsand delivery tools for use therewith for implantable defibrillators.Various electrode designs are shown below, as are new tools forimplanting such devices. Some electrodes have a width or surface areathat is larger than typical shocking electrodes. The increased surfacearea or shadow may reduce the defibrillation threshold. Some electrodesmay move between a low profile delivery configuration and an expandedimplanted configuration. Embedded electrodes and/or printed circuitelectrodes may also be used to reduce the defibrillation threshold.

This overview is intended to provide an overview of subject matter ofthe present patent application. It is not intended to provide anexclusive or exhaustive explanation of the invention. The detaileddescription is included to provide further information about the presentpatent application.

BRIEF DESCRIPTION OF THE DRAWINGS

In the drawings, which are not necessarily drawn to scale, like numeralsmay describe similar components in different views. Like numerals havingdifferent letter suffixes may represent different instances of similarcomponents. The drawings illustrate generally, by way of example, butnot by way of limitation, various embodiments discussed in the presentdocument.

FIG. 1 shows an illustrative implantable cardiac rhythm managementsystem;

FIG. 2 shows an illustrative method in block flow form;

FIGS. 3A-3C show an illustrative electrode for use with an implantablecardiac rhythm management system;

FIGS. 3D-3E show another illustrative electrode for use with animplantable cardiac rhythm management system;

FIGS. 4A-4D show another illustrative electrode for use with animplantable cardiac rhythm management system;

FIGS. 5A-5B show another illustrative electrode for use with animplantable cardiac rhythm management system;

FIGS. 6A-6B show another illustrative electrode for use with animplantable cardiac rhythm management system;

FIG. 7 shows another illustrative electrode for use with an implantablecardiac rhythm management system;

FIGS. 8A-8E show another illustrative electrode for use with animplantable cardiac rhythm management system;

FIGS. 9A-9B show another illustrative electrode for use with animplantable cardiac rhythm management system;

FIG. 10 shows another illustrative electrode for use with an implantablecardiac rhythm management system;

FIG. 11 shows an illustrative prior art electrode introducer tool;

FIGS. 12A-12C show an illustrative tunneling tool;

FIGS. 13A-13D show another illustrative tunneling tool;

FIGS. 14A-14C show another illustrative tunneling tool;

FIGS. 15A-15E show an illustrative tunneling tool having an inflatableelement;

FIGS. 16A-16B show another illustrative tunneling tool having aninflatable element;

FIGS. 17A-17G show several details and variants for another illustrativetunneling tool;

FIGS. 18A-18B show another illustrative tunneling tool;

FIGS. 19A-19B show another illustrative tunneling tool;

FIGS. 20A-20B show another illustrative tunneling tool; and

FIGS. 21A-21B show another illustrative tunneling tool.

DETAILED DESCRIPTION

FIG. 1 shows the subcutaneous implantable cardioverter-defibrillator(S-ICD) System™ from Cameron Health, Inc., and Boston ScientificCorporation, as implanted in a patient. The system is implanted in apatient 10 with a canister 12 in the left axilla at about the level ofthe cardiac apex. A lead 14 is placed subcutaneously, beneath the skinand over the ribcage of the patient, with a first portion extendingalong the inframammary crease to the xiphoid, and then superiorlyparallel to and about 1-2 cm to the left of the sternum. A proximalsense electrode 16, shocking coil electrode 18, and distal tip senseelectrode 20 are provided along the parasternal portion of the lead 14.The entire system is implanted outside of the ribcage.

The canister 12 may include componentry appropriate for communication(such as RF communication, inductive telemetry or other suitablecommunication linkage) with an external device such as a programmer 22.For example, during an implantation procedure, once the canister 12 andlead 14 are placed, the programmer 22 may be used to activate thecanister 12 and/or direct/observe diagnostic or operational tests. Afterimplantation, the programmer 22 may be used to non-invasively determinethe status and history of the implanted device. The programmer 22 incombination with the canister 12 may also allow annunciation ofstatistics, errors, history and potential problems to the user/medicalpractitioner, and may also allow for updating of programming in thecanister 12. Though not shown, the system may also be used with a remotemonitor, as such systems are known in the art.

The placement of a defibrillator system entirely subcutaneously can beassociated with a need for higher voltage, power and/or current whendelivering therapy defibrillation and/or pacing therapy. One effect ofhigher power and/or voltage requirements is that the size of theimplantable canister 12 may be limited by a need, for example, toinclude two or even three batteries and/or high power capacitors. Forexample, the S-ICD System® as approved by the United States Food andDrug Administration in 2012 had three batteries and three high powercapacitors, which consumed the vast majority of the implantable devicevolume.

One proposed solution for reduction of power is placement of the lead 14beneath the sternum, such as discussed in Guenther et al., SubsternalLead Implantation: A Novel Option to Manage DFT Failure in S-ICDPatients, Clin. Res. Cardiol (2015) 104:189-191. Some tools and methodsto perform substernal implantation are discussed in U.S. ProvisionalPatent Application 62/195,695, titled SUBSTERNAL PLACEMENT OF A PACINGAND/OR DEFIBRILLATING ELECTRODE, the disclosure of which is incorporatedherein by reference. The enhancements suggested in the present patentapplication may be implemented in subcutaneous-only and/or substernallead systems. It should be noted that while the example of FIG. 1 showsa device implanted without any leads and/or electrodes in or on theheart, the enhancements herein may also be used in systems that includeone or more such leads or electrodes. Additionally, while FIG. 1 shows aleft lateral or axillary canister 12 with a parasternal lead 14, otherpositions may be used instead such as those shown in U.S. Pat. Nos.6,721,597 and 7,149,575, the disclosure of which are incorporated hereinby reference. For example, and without limitation, the canister 12 maybe placed anterior, right-sided, posterior, abdominal,pectoral/infraclavicular, or placed in any other desired position, withthe lead 14 extending vertically or horizontally on the anterior, side,or posterior of the patient's torso, for example. Additionalenhancements are desired, both in terms of the electrode and lead to beimplanted as well as methods and tools for such implantation.

FIG. 2 shows an illustrative method of implantation in block flow form.In this example, the patient is prepared at 200 for implantation of thedevice. The patient may undergo screening and testing to ensureappropriate patient selection using device indications and the like.Optionally, in some examples a pre-screen check may be performed asdisclosed in U.S. Pat. No. 8,079,959, titled PATIENT SCREENING TOOLS FORIMPLANTABLE CARDIAC STIMULUS SYSTEMS, the disclosure of which isincorporated herein by reference. The patient may also be prepared bydelivery of anesthetics and or other medications and sterile field, etc.will be prepared, as is known in the art.

One or more incisions are then made as indicated at 202. The incisionsmay include, for example, those suggested by FIG. 1 including anincision in the left axilla and another at or near the xiphoid process.Some procedures may further include a superior incision at or inferiorto the manubrium for a subcutaneous implant procedure. Methods anddevices for subcutaneous implantation of a lateral/axillary canisterwith parasternal lead are discussed further in U.S. Pat. No. 8,157,813,titled APPARATUS AND METHOD FOR SUBCUTANEOUS ELECTRODE INSERTION, and USPG Publication No. 20120029335, titled SUBCUTANEOUS LEADS AND METHODS OFIMPLANT AND EXPLANT, the disclosures of which are incorporated herein byreference.

Alternatively, a substernal implant procedure may include a xiphoid orsub-xiphoid incision allowing tunneling along the back side of thesternum, such as in U.S. Provisional Patent Application No. 62/195,695,titled SUBSTERNAL PLACEMENT OF A PACING OR DEFIBRILLATING ELECTRODE, thedisclosure of which is incorporated herein by reference. It has alsobeen proposed to use a single-incision implant procedure with asteerable insertion tool, for example in U.S. Provisional PatentApplication No. 62/195,700, titled MINIMALLY INVASIVE METHOD TO IMPLANTA SUBCUTANEOUS ELECTRODE, or U.S. Pat. No. 6,647,292, titled UNITARYSUBCUTANEOUS ONLY IMPLANTABLE CARDIOVERTER-DEFIBRILLATOR AND OPTIONALPACER the disclosures of which are incorporated herein by reference. Ifa subcutaneous implant position other than that shown in FIG. 1 isdesired, the incisions may be placed elsewhere as desired, including forexample, for use with right sided, anterior-posterior, or other implantpositions such as shown in U.S. Pat. No. 6,721,597, titled SUBCUTANEOUSONLY IMPLANTABLE CARDIOVERTER DEFIBRILLATOR AND OPTIONAL PACER, and U.S.Pat. No. 7,149,575, titled SUBCUTANEOUS CARDIAC STIMULATOR DEVICE HAVINGAN ANTERIORLY POSITIONED ELECTRODE, the disclosures of which areincorporated herein by reference.

A subcutaneous or substernal tunnel for emplacement of a lead is thenmade, as indicated at 204. The tunnel, for the most part, is formed byseparating tissue layers, as opposed to tearing through tissue layersthemselves, and is desirably made as close to the fascia as it can inorder to avoid capturing subcutaneous fat or other tissue in theelectrical therapy field. Tunneling may be performed using a blunt-ended(for example, bullet-shaped) and stiff electrode insertion toolspecially made for the purpose of tunneling to implant a subcutaneouselectrode.

With the tunnel formed, a lead is emplaced as shown at 206. Variousmethods for emplacing the lead can be used. In some examples, a suturemay be attached to an end of a lead after being passed through thesubcutaneous tunnel and the suture is then used to pull the end of thelead from one incision to another (see, for example, US PG PublicationNo. 20120029335 and or the labeling of the S-ICD System as originallyapproved by the FDA in PMA P11042). In other examples, tunneling may beperformed with a splittable sheath placed over a tunneling tool, and thetunneling tool is removed while keeping the sheath in place, such thatthe lead can be inserted into the splittable sheath to the desiredposition. In other examples a lead and an insertion tool may includeattachment features, such as tines, eyelets or other features, allowingattachment therebetween, as shown for example in U.S. Pat. No.7,657,322, titled SUBCUTANEOUS ELECTRODE WITH IMPROVED CONTACT SHAPE FORTRANSTHORACIC CONDUCTION, and U.S. Pat. No. 8,718,793, titled ELECTRODEINSERTION TOOLS, LEAD ASSEMBLIES, KITS AND METHODS FOR PLACEMENT OFCARDIAC DEVICE ELECTRODES, the disclosures of which are incorporatedherein by reference. Lead placement may also include securing the leadin a desired position by the use of sutures, clips, suture sleeves, orother devices and steps. For example, a suture sleeve integrated into oron the lead, or a suture hole, may be secured at a desired location suchas (assuming implant as in FIG. 1) at the end of the lead along thesternum or near the xiphoid, with the suture being secured desirable tothe fascia for secure anchoring. U.S. Provisional Patent Application No.62/195,695 also includes some discussion of anchoring for a substernallocation.

A pocket for receiving the canister of the device is also prepared, asshown at 208. Pocket preparation 208 may be done manually or using ablunt tool, for example. The ICD canister is then placed in the preparedpocket as shown at 210, and the lead is attached to the ICD canister, asshown at 212. The exact order of steps may vary; in some examples, step212 may precede step 210 such that the lead is attached to the canisterprior to placement of the canister. Step 212 may include, for example,the use of a setscrew to secure the lead and canister together. Step 210may also include, again, suturing the ICD canister down to the fascia,if desired.

The system then may undergo configuration and testing as indicated at214. Configuration may include setting various parameters, such asparameters for determining whether a treatable arrhythmia is occurring(for example, setting rate boundaries to define ventricular fibrillationand ventricular tachyarrhythmia for the patient), setting sensingparameters such as sensing vector selection, gain setting or otherparameters, setting therapy parameters including pacing anddefibrillation therapy parameters, or any other suitable parameters.System test may include the performance of induction testing, in whichthe patient's heart is placed in an arrhythmic state (such by inducingventricular fibrillation by application of a stimulus on the T-wave, along DC signal, or the use of a relatively fast 40 to 80 Hz signal), andthe device is allowed detect the arrhythmia and deliver therapy toensure both that the device can sense appropriately and that thedelivered therapy will work for its intended purposes.

If system configuration and testing is completed appropriately in block214, the procedure can end by closing all incisions as shown at 216and/or other appropriate post-surgery steps. As noted above, the stepsin FIG. 2 may be performed in an order other than that shown. Followingthe close of surgery 216, other testing and configuration steps may beperformed as well prior to release of the patient, such as furthersetting of the sensing configuration, if desired.

FIG. 3A shows a top view of an illustrative lead and electrode assembly300 for use with an implantable cardiac rhythm management system, suchas, but not limited to the S-ICD System™ from Cameron Health, Inc., andBoston Scientific Corporation described above with respect to FIG. 1.While not explicitly shown, the lead 302 may include a proximal end witha proximal pin which along with additional contacts serves in thisexample as an electrical contact, which may be separated by insulatingmaterial. The proximal end may further include seal plugs. A proximalplug sheath may be provided for a region near the proximal end of thelead 302. The pin, contacts, insulating material, and seal plugs may beconfigured for placement inside a bore on a header of an implantablepulse generator. In some embodiments, the proximal end may have standardplug designs (DF-1, DF-4, etc.) for use in other devices. The lead 302extends from this proximal configuration through an intermediate region304 to a distal end having a proximal electrode 306, a coil electrode308, and a distal tip electrode 310. The positioning and/or spacing ofthe electrodes 306, 308, 310 may be adjusted and/or reconfigured tooptimize sensing and/or therapy delivery. For example, both sensingelectrodes 306, 310 may be placed proximal to or distal to the coilelectrode 308. This is just an example. It is contemplated that theelectrodes 306, 308, 310 may be placed beneath the skin and over theribcage of the patient. In other embodiments, the electrodes 306, 308,310 may be placed in a substernal location using an implant procedurethat may include a xiphoid or sub-xiphoid incision that allows fortunneling along the back side of the sternum. The electrodes 306, 308,310 may also be placed elsewhere as desired including for example, foruse with right sided, anterior-posterior, or other implant positions.Some illustrative discussion of a lead as used in the S-ICD™ System isprovided in U.S. Pat. No. 8,483,841.

Lead 302 is shown for illustrative purposes, however, other designs andconfigurations including fewer, more or different electrodes 306, 308,310, or contacts, may be used. Additional design elements such asbifurcation or other splitting, paddles or other designs may be usedinstead with an anchoring device attached at the time of implant. Thelead 302 is not shown as including a passageway for a stylet to useduring introduction, however, a lumen for that purpose may be providedif desired. In the illustrative example, the lead 302 has a body thatcontains passageways having connectors therein for coupling the proximalcontacts to the coil 308, proximal electrode 306, and/or distalelectrode 310.

The distal tip electrode 310 is shown with a suture hole 312. The suturehole 312 may be coupled to a base portion 314. Other designs may beused. In some embodiments, a suture hole 312, or other fixation means,may not be required and/or may not be provided.

As used herein, a coil electrode may be a helically wound element,filament, or strand. The filament forming the coil may have a generallyround or a generally flat (e.g. rectangular) cross-sectional shape, asdesired. However, other cross-sectional shapes may be used. The coilelectrode may have a closed pitch, or in other words, adjacent windingsmay contact one another. Alternatively, the coil electrode may have anopen pitch such that adjacent windings are spaced a distance from oneanother. The pitch may be uniform or varied along a length of the coilelectrode. A varied pitch may be gradual tapered changes in pitch orabrupt or step-wise changes in pitch.

The shocking coil electrode 308 may have a generally flattenedcross-sectional configuration, although this is not required. Forexample, referring to FIGS. 3B and 3C which illustrate an end view and aperspective view, respectively, of the illustrative coil electrode 308,the coil electrode 308 may have a cross-sectional shape that generallytakes the form of an oval. The cross-sectional shape may have two curvedends and two parallel sides connecting the curved ends. Othercross-sectional shapes may also be used, including, but not limited to,rectangular, polygonal, circular, square, etc. The coil electrode 308may have a length L that is generally larger than a width W. The width Wmay be generally larger than a height H of the electrode 308. The lengthL of the electrode 308 may be in the range of 50 to 110 millimeters(mm), 60 to 100 mm, 70 to 90 mm or about 80 mm. The width W of theelectrode 308 may be in the range of 1 to 40 mm, 5 to 35 mm, 10 to 30mm, 15 to 25 mm, or about 20 mm. The height H of the electrode 308 maybe in the range of 0.5 mm to 6 mm, 1 mm to 5 mm, 2 mm to 4 mm, or about3 mm. The coil electrode 308 may have a larger surface area and/orshadow than a typical shocking coil electrode. It is contemplated thatincreasing the surface area and/or shadow of the shocking electrode 308may allow the defibrillation threshold to be lowered which may allow thecanister, such as canister 12, to have a smaller profile.

The coil electrode 308 may be formed from a round or flat (ribbon) wire,as desired. In some embodiments, the coil electrode 308 may be formed asa subassembly and placed over the lead body 302. Alternatively, the coilelectrode 308 may be formed as a unitary structure with or otherwiseformed over the lead body 302. While not explicitly shown, the coilelectrode 308 may include a lumen or passageway for receiving a styletor other delivery aid. In some instances, adjacent windings 316 of thecoil electrode 308 may be in contact with one another while in otherinstances adjacent windings 316 may be spread out or spaced a distancefrom one another, as desired.

A thin permeable membrane may be positioned over the coil 308 and/orother portions of the lead and electrode assembly 300 to inhibit tissueingrowth. Coatings, such as, but not limited to expandedpolytetrafluoroethylene (ePTFE) may also be applied to the lead andelectrode assembly 300, or portions thereof, to facilitate extractionand/or to reduce tissue ingrowth. In some embodiments, one or more ofthe electrodes 306, 308, 310 may be include a high capacitive coatingsuch as, but not limited to iridium oxide (IrOx), titanium nitride(TiN), or other “fractal” coatings which may be used, for example, toimprove electrical performance. The lead and electrode assembly 300, orportions thereof, may include treatments in local areas to increaseattachment, such as, for example, along the length of the lead, near anelectrode, or at or near the distal tip, the inclusion of a roughenedsurface, a surface of different polymer or other material, or a local acoating to encourage tissue growth such as a steroid.

FIG. 3D shows a top view of an illustrative lead and electrode assembly350 for use with an implantable cardiac rhythm management system, suchas, but not limited to the S-ICD System™ from Cameron Health, Inc., andBoston Scientific Corporation described above with respect to FIG. 1.While not explicitly shown, the lead 352 may include a proximal end witha proximal pin which along with additional contacts serves in thisexample as an electrical contact, which may be separated by insulatingmaterial. The proximal end may further include seal plugs. A proximalplug sheath may be provided for a region near the proximal end of thelead 352. The pin, contacts, insulating material, and seal plugs may beconfigured for placement inside a bore on a header of an implantablepulse generator. In some embodiments, the proximal end may have standardplug designs (DF-1, DF-4, etc.) for use in other devices. The lead 352extends from this proximal configuration through an intermediate region354 to a distal end having a proximal electrode 356, a solid surfaceelectrode 358, and a distal tip electrode 360. The positioning and/orspacing of the electrodes 356, 358, 360 may be adjusted and/orreconfigured to optimize sensing and/or therapy delivery. For example,both sensing electrodes 356, 360 may be placed proximal to or distal tothe solid surface electrode 358. This is just an example. It iscontemplated that the electrodes 356, 358, 360 may be placed beneath theskin and over the ribcage of the patient. In other embodiments, theelectrodes 356, 358, 360 may be placed in a substernal location using animplant procedure that may include a xiphoid or sub-xiphoid incisionthat allows for tunneling along the back side of the sternum. Theelectrodes 356, 358, 360 may also be placed elsewhere as desiredincluding for example, for use with right sided, anterior-posterior, orother implant positions. Some illustrative discussion of a lead as usedin the S-ICD™ System is provided in U.S. Pat. No. 8,483,841.

Lead 352 is shown for illustrative purposes, however, other designs andconfigurations including fewer, more or different electrodes 356, 358,360, or contacts, may be used. Additional design elements such asbifurcation or other splitting, paddles or other designs may be usedinstead with an anchoring device attached at the time of implant. Thelead 352 is not shown as including a passageway for a stylet to useduring introduction, however, a lumen for that purpose may be providedif desired. In the illustrative example, the lead 352 has a body thatcontains passageways having connectors therein for coupling the proximalcontacts to the solid surface electrode 358, proximal electrode 356,and/or distal electrode 360.

The distal tip electrode 360 is shown with a suture hole 362. The suturehole 362 may be coupled to a base portion 364. Other designs may beused. In some embodiments, a suture hole 362, or other fixation means,may not be required and/or may not be provided.

As used herein, a solid surface electrode may have a generally,substantially, or entirely solid outer surface. In some cases, the solidsurface electrode may be a solid unitary metallic structure. In otherembodiments, the solid surface electrode may be a rigid polymerstructure with a metallic shell disposed over the polymeric structure.It is contemplate that the metallic shell may be placed over thepolymeric structure in such a way to minimize gaps or openings in theconductive portion.

The shocking solid surface electrode 358 may have a generally flattenedcross-sectional configuration, although this is not required. Forexample, referring to FIG. 3E which illustrates a perspective view ofthe illustrative electrode 358, the solid surface electrode 358 may havea cross-sectional shape that generally takes the form of an oval. Thecross-sectional shape may have two curved ends and two parallel sidesconnecting the curved ends. Other cross-sectional shapes may also beused, including, but not limited to, rectangular, polygonal, circular,square, etc. The solid surface electrode 358 may have a length L that isgenerally larger than a width W. The width W may be generally largerthan a height H of the electrode 358. The length L of the electrode 358may be in the range of 50 to 110 millimeters (mm), 60 to 100 mm, 70 to90 mm or about 80 mm. The width W of the electrode 358 may be in therange of 1 to 40 mm, 5 to 35 mm, 10 to 30 mm, 15 to 25 mm, or about 20mm. The height H of the electrode 358 may be in the range of 0.5 mm to 6mm, 1 mm to 5 mm, 2 mm to 4 mm, or about 3 mm. The solid surfaceelectrode 358 may have a larger surface area and/or shadow than atypical shocking coil electrode. It is contemplated that increasing thesurface area and/or shadow of the shocking electrode 358 may allow thedefibrillation threshold to be lowered which may allow the canister,such as canister 12, to have a smaller profile.

In some embodiments, the solid surface electrode 358 may be formed as asubassembly and placed over the lead body 352. Alternatively, the solidsurface electrode 358 may be formed as a unitary structure with orotherwise formed over the lead body 352. While not explicitly shown, thesolid surface electrode 358 may include a lumen or passageway forreceiving a stylet or other delivery aid.

A thin permeable membrane may be positioned over the coil 358 and/orother portions of the lead and electrode assembly 350 to inhibit tissueingrowth. Coatings, such as, but not limited to expandedpolytetrafluoroethylene (ePTFE) may also be applied to the lead andelectrode assembly 350, or portions thereof, to facilitate extractionand/or to reduce tissue ingrowth. In some embodiments, one or more ofthe electrodes 356, 358, 360 may be include a high capacitive coatingsuch as, but not limited to iridium oxide (IrOx), titanium nitride(TiN), or other “fractal” coatings which may be used, for example, toimprove electrical performance. The lead and electrode assembly 350, orportions thereof, may include treatments in local areas to increaseattachment, such as, for example, along the length of the lead, near anelectrode, or at or near the distal tip, the inclusion of a roughenedsurface, a surface of different polymer or other material, or a local acoating to encourage tissue growth such as a steroid

FIGS. 4A and 4B show a top view of another illustrative lead andelectrode assembly 400 for use with an implantable cardiac rhythmmanagement system, such as, but not limited to the S-ICD System™ fromCameron Health, Inc., and Boston Scientific Corporation described withrespect to FIG. 1. In some embodiments, the illustrated assembly 400 maybe configured to move between a collapsed or delivery configuration,shown in FIG. 4A and an expanded or implanted configuration, shown inFIG. 4B. However, it is contemplated that the illustrative lead andelectrode assembly 400 of FIG. 4A may be both the delivery configurationand the implanted configuration. Similarly, the illustrative lead andelectrode assembly 400 of FIG. 4B may be both the delivery configurationand the implanted configuration.

While not explicitly shown, the lead 402 may include a proximal end witha proximal pin which along with additional contacts serves in thisexample as an electrical contact, which may be separated by insulatingmaterial. The lead 402 may be similar in form and function to the lead302 described above. The proximal end may further include seal plugs. Aproximal plug sheath may be provided for a region near the proximal endof the lead 402. The pin, contacts, insulating material, and seal plugsmay be configured for placement inside a bore on a header of animplantable pulse generator. In some embodiments, the proximal end mayhave standard plug designs (DF-1, DF-4, etc.) for use in other devices.The lead 402 extends from this proximal configuration through anintermediate region 404 to a distal end having a proximal electrode 406,a coil electrode 408, and a distal tip electrode 410. The positioningand/or spacing of the electrodes 406, 408, 410 may be adjusted and/orreconfigured to optimize sensing and/or therapy delivery. For example,both sensing electrodes 406, 410 may be placed proximal to or distal tothe coil electrode 408. This is just an example. It is contemplated thatthe electrodes 406, 408, 410 may be placed beneath the skin and over theribcage of the patient. In other embodiments, the electrodes 406, 408,410 may be placed in a substernal location using an implant procedurethat may include a xiphoid or sub-xiphoid incision that allows fortunneling along the back side of the sternum. The electrodes 406, 408,410 may also be placed elsewhere as desired including for example, foruse with right sided, anterior-posterior, or other implant positions.

Lead 402 is shown for illustrative purposes, however, other designs andconfigurations including fewer, more or different electrodes 406, 408,410, or contacts, may be used. Additional design elements such asbifurcation or other splitting, paddles or other designs may be usedinstead with an anchoring device attached at the time of implant. Thelead 402 is not shown as including a passageway for a stylet to useduring introduction, however, a lumen for that purpose may be providedif desired. In the illustrative example, the lead 402 has a body thatcontains passageways having connectors therein for coupling the proximalcontacts to the coil 408, proximal electrode 406, and/or distalelectrode 410.

The distal tip electrode 410 is shown with a suture hole 412. The suturehole 412 may be coupled to a base portion 414. Other designs may beused. In some embodiments, a suture hole 412, or other fixation means,may not be required and/or may not be provided.

The coil electrode 408 may be formed from two or more individual coilelectrodes 416 a, 416 b. While the coil electrode 408 is illustrated asincluding two coil electrodes 416 a, 416 b, the coil electrode 408 mayincluding any number of individual coil electrodes desired, such as, butnot limited to, one, two, three, four, five, or more. Further, in eitherconfiguration, the coil electrodes 416 a, 416 b may be positioned closeto one another (e.g. touching) or spaced a distance, as desired. Thecoil electrode 408 may be affixed to the lead body 402 at its proximalend 422 and its distal end 424. While not explicitly shown, in someembodiments, the lead body 402 may include a portion that extendsbetween the proximal end 422 and the distal end 424 of the coilelectrode 408. It is contemplated that the lead body 402 may include atelescoping feature or nested tubular members that allows the proximalend 422 and/or distal end 424 of the coil electrode 408 to be movedalong a longitudinal axis of the system 400, such as in the direction ofarrows 418 a, 418 b, shown in FIG. 4B. In other embodiments, the leadbody 402 may be disposed within one or both of the coil electrodes 416a, 416 b. While not explicitly shown, the coil electrode 408 may includea lumen or passageway for receiving a stylet or other delivery aid.

Each of the coil electrodes 416 a, 416 b may be formed from a round orflat (ribbon) wire, as desired. In some instances, adjacent windings ofthe coil electrodes 416 a, 416 b may be in contact with one anotherwhile in other instances adjacent windings may be spread out or spaced adistance from one another, as desired. It is contemplated that theindividual coil electrodes 416 a, 416 b may have the same or similarstructure, or may be different, as desired. For example one coilelectrode 416 a may be more tightly wound than the other 416 b. This isjust an example.

A thin permeable membrane may be positioned over the coil 408 and/orother portions of the lead and electrode assembly 400 to inhibit tissueingrowth. A single permeable membrane may surround both coil electrodes416 a, 416 b. Alternatively, or additionally, separate membranes maysurround each of the coil electrodes 416 a, 416 b individually.Coatings, such as, but not limited to expanded polytetrafluoroethylene(ePTFE) may also be applied to the lead and electrode assembly 400, orportions thereof, to facilitate extraction and/or to reduce tissueingrowth. In some embodiments, one or more of the electrodes 406, 408,410 may be include a high capacitive coating such as, but not limited toiridium oxide (IrOx), titanium nitride (TiN), or other “fractal”coatings which may be used, for example, to improve electricalperformance. The lead and electrode assembly 400, or portions thereof,may include treatments in local areas to increase attachment, such as,for example, along the length of the lead, near an electrode, or at ornear the distal tip, the inclusion of a roughened surface, a surface ofdifferent polymer or other material, or a local a coating to encouragetissue growth such as a steroid.

The coil electrodes 416 a, 416 b may be actuatable or expandable from adelivery configuration having a first width 426, shown in FIG. 4A, to animplanted configuration having a second larger width 428, as shown inFIG. 4B. While the embodiments shown in FIGS. 4A and 4B are described asmovable between two different configurations, it is contemplated thelead and electrode assembly 400 may be fixed in either arrangement. Inother words, in some embodiments the electrodes 416 a, 416 b may bemovable relative to one another while in other embodiments, theelectrodes 416 a, 416 b may be in a fixed arrangement relative to oneanother. It is contemplated that the coil electrode 408, in either thedelivery configuration or the implanted configuration, may be similar insize to the coil electrode 308 described above. The coil electrode 408may have a larger surface area and/or shadow than a typical shockingcoil electrode. It is contemplated that increasing the surface areaand/or shadow may allow the defibrillation threshold to be lowered whichmay allow the canister, such as canister 12, to have a smaller profile.

The lead and electrode assembly 400 may be actuated between the deliveryconfiguration and the implanted configuration using any number ofdeployment mechanisms. In one example, the distal electrode 410 may besecured to the tissue. Once the distal end has been secured, the leadbody 402 may be distally advanced to apply a pushing force to theproximal end 422 of the coil electrode 408. This may cause the coilelectrodes 416 a, 416 b to bias outward, for example in directions 420a, 420 b, shown in FIG. 4B while also shortening in length, as shown atarrows 418 a, 418 b. It is contemplated that the same result may beachieved by applying a proximal, or pulling force to the distal end 424of the coil. In yet another example, the coil electrodes 416 a, 416 bmay be formed in the expanded configuration illustrated in FIG. 4B. Thecoil electrodes 416 a, 416 b may be compressed into a lower profiledelivery configuration through the application of a biasing force. Forexample, when the coil electrodes 416 a, 416 b are disposed within adelivery tool, the delivery tool may maintain the coil electrodes 416 a,416 b in a reduced profile configuration.

FIG. 4C shows a top view of another illustrative lead and electrodeassembly 430 for use with an implantable cardiac rhythm managementsystem, such as, but not limited to the S-ICD System™ from CameronHealth, Inc., and Boston Scientific Corporation described with respectto FIG. 1. While not explicitly shown, the illustrated assembly 430 maybe configured to move between a collapsed or delivery configuration andan expanded or implanted configuration such as that described withrespect to FIGS. 4A and 4B. However, this is not required. It iscontemplated that the illustrative lead and electrode assembly 430 ofFIG. 4C may be both the delivery configuration and the implantedconfiguration.

While not explicitly shown, the lead 432 may include a proximal end witha proximal pin which along with additional contacts serves in thisexample as an electrical contact, which may be separated by insulatingmaterial. The lead 432 may be similar in form and function to the lead302 described above. The proximal end may further include seal plugs. Aproximal plug sheath may be provided for a region near the proximal endof the lead 432. The pin, contacts, insulating material, and seal plugsmay be configured for placement inside a bore on a header of animplantable pulse generator. In some embodiments, the proximal end mayhave standard plug designs (DF-1, DF-4, etc.) for use in other devices.The lead 432 extends from this proximal configuration through anintermediate region 434 to a distal end having a proximal electrode 436,a coil electrode 438, and a distal tip electrode 440. The positioningand/or spacing of the electrodes 436, 438, 440 may be adjusted and/orreconfigured to optimize sensing and/or therapy delivery. For example,both sensing electrodes 436, 440 may be placed proximal to or distal tothe coil electrode 438. It is contemplated that the electrodes 436, 438,440 may be placed beneath the skin and over the ribcage of the patient.In other embodiments, the electrodes 436, 438, 440 may be placed in asubsternal location using an implant procedure that may include axiphoid or sub-xiphoid incision that allows for tunneling along the backside of the sternum. The electrodes 436, 438, 440 may also be placedelsewhere as desired including for example, for use with right sided,anterior-posterior, or other implant positions.

Lead 432 is shown for illustrative purposes, however, other designs andconfigurations including fewer, more or different electrodes 436, 438,440, or contacts, may be used. Additional design elements such asbifurcation or other splitting, paddles or other designs may be usedinstead with an anchoring device attached at the time of implant. Thelead 432 is not shown as including a passageway for a stylet to useduring introduction, however, a lumen for that purpose may be providedif desired. In the illustrative example, the lead 432 has a body thatcontains passageways having connectors therein for coupling the proximalcontacts to the coil 438, proximal electrode 436, and/or distalelectrode 440.

The distal tip electrode 440 is shown with a suture hole 442. The suturehole 442 may be coupled to a base portion 444. Other designs may beused. In some embodiments, a suture hole 442, or other fixation means,may not be required and/or may not be provided.

The coil electrode 438 may be formed from a plurality of individual coilelectrodes 446. While the coil electrode 438 is illustrated as includingfive coil electrodes 446, the coil electrode 438 may including anynumber of individual coil electrodes desired, such as, but not limitedto, one, two, three, four, five, or more. Further, the coil electrodes446 may be positioned close to one another (e.g. touching) or spaced adistance, as desired. In some embodiments, the coil electrodes 446 mayextend generally parallel to one another and to a longitudinal axis ofthe lead 432. It is contemplated that the coil electrode 438, may besimilar in size to the coil electrode 308 described above. The coilelectrode 438 may have a larger surface area and/or shadow than atypical shocking coil electrode. It is contemplated that increasing thesurface area and/or shadow may allow the defibrillation threshold to belowered which may allow the canister, such as canister 12, to have asmaller profile.

The coil electrode 438 may be affixed to the lead body 432 at itsproximal end 448 and its distal end 450. While not explicitly shown, insome embodiments, the lead body 432 may include a portion that extendsbetween the proximal end 448 and the distal end 450 of the coilelectrode 438. In other embodiments, the lead body 432 may be disposedwithin one or more of the coil electrodes 446. While not explicitlyshown, the coil electrode 438 may include a lumen or passageway forreceiving a stylet or other delivery aid.

Each of the coil electrodes 446 may be formed from a round or flat(ribbon) wire, as desired. In some instances, adjacent windings of thecoil electrodes 446 may be in contact with one another while in otherinstances adjacent windings may be spread out or spaced a distance fromone another, as desired. It is contemplated that the individual coilelectrodes 446 may have the same or similar structure, or may bedifferent, as desired. For example one coil electrode may be moretightly wound than another. This is just an example.

A thin permeable membrane may be positioned over the coil 438 and/orother portions of the lead and electrode assembly 430 to inhibit tissueingrowth. In some embodiments, a single permeable membrane may surroundthe plurality of coil electrodes 446. Alternatively, or additionally,separate membranes may surround each of the coil electrodes 446individually. Coatings, such as, but not limited to expandedpolytetrafluoroethylene (ePTFE) may also be applied to the lead andelectrode assembly 430, or portions thereof, to facilitate extractionand/or to reduce tissue ingrowth. In some embodiments, one or more ofthe electrodes 436, 438, 440 may be include a high capacitive coatingsuch as, but not limited to iridium oxide (IrOx), titanium nitride(TiN), or other “fractal” coatings which may be used, for example, toimprove electrical performance. The lead and electrode assembly 430, orportions thereof, may include treatments in local areas to increaseattachment, such as, for example, along the length of the lead, near anelectrode, or at or near the distal tip, the inclusion of a roughenedsurface, a surface of different polymer or other material, or a local acoating to encourage tissue growth such as a steroid.

FIG. 4D shows a top view of another illustrative lead and electrodeassembly 460 for use with an implantable cardiac rhythm managementsystem, such as, but not limited to the S-ICD System™ from CameronHealth, Inc., and Boston Scientific Corporation described with respectto FIG. 1. While not explicitly shown, the illustrated assembly 460 maybe configured to move between a collapsed or delivery configuration andan expanded or implanted configuration such as that described withrespect to FIGS. 4A and 4B. However, this is not required. It iscontemplated that the illustrative lead and electrode assembly 460 ofFIG. 4D may be both the delivery configuration and the implantedconfiguration.

While not explicitly shown, the lead 462 may include a proximal end witha proximal pin which along with additional contacts serves in thisexample as an electrical contact, which may be separated by insulatingmaterial. The lead 462 may be similar in form and function to the lead302 described above. The proximal end may further include seal plugs. Aproximal plug sheath may be provided for a region near the proximal endof the lead 462. The pin, contacts, insulating material, and seal plugsmay be configured for placement inside a bore on a header of animplantable pulse generator. In some embodiments, the proximal end mayhave standard plug designs (DF-1, DF-4, etc.) for use in other devices.The lead 462 extends from this proximal configuration through anintermediate region 464 to a distal end having a proximal electrode 466,a coil electrode 468, and a distal tip electrode 470. The positioningand/or spacing of the electrodes 466, 468, 470 may be adjusted and/orreconfigured to optimize sensing and/or therapy delivery. For example,both sensing electrodes 466, 470 may be placed proximal to or distal tothe coil electrode 468. It is contemplated that the electrodes 466, 468,470 may be placed beneath the skin and over the ribcage of the patient.In other embodiments, the electrodes 466, 468, 470 may be placed in asubsternal location using an implant procedure that may include axiphoid or sub-xiphoid incision that allows for tunneling along the backside of the sternum. The electrodes 466, 468, 470 may also be placedelsewhere as desired including for example, for use with right sided,anterior-posterior, or other implant positions.

Lead 462 is shown for illustrative purposes, however, other designs andconfigurations including fewer, more or different electrodes 466, 468,470, or contacts, may be used. Additional design elements such asbifurcation or other splitting, paddles or other designs may be usedinstead with an anchoring device attached at the time of implant. Thelead 462 is not shown as including a passageway for a stylet to useduring introduction, however, a lumen for that purpose may be providedif desired. In the illustrative example, the lead 462 has a body thatcontains passageways having connectors therein for coupling the proximalcontacts to the coil 468, proximal electrode 466, and/or distalelectrode 470.

The distal tip electrode 470 is shown with a suture hole 472. The suturehole 472 may be coupled to a base portion 474. Other designs may beused. In some embodiments, a suture hole 472, or other fixation means,may not be required and/or may not be provided.

The coil electrode 468 may be formed from a plurality of individual coilelectrodes 476. While the coil electrode 468 is illustrated as includingfive coil electrodes 476, the coil electrode 468 may including anynumber of individual coil electrodes desired, such as, but not limitedto, one, two, three, four, five, or more. Further, the coil electrodes476 may be positioned close to one another (e.g. touching) or spaced adistance, as desired. In some embodiments, some or all of the coilelectrodes 476 may have a generally curved configuration such that thecoil electrode 468 is generally oval in its overall shape. This is notrequired. The coil electrode 468 may take any shape desired. It iscontemplated that the coil electrode 468, may be similar in size to thecoil electrode 308 described above. The coil electrode 468 may have alarger surface area and/or shadow than a typical shocking coilelectrode. It is contemplated that increasing the surface area and/orshadow may allow the defibrillation threshold to be lowered which mayallow the canister, such as canister 12, to have a smaller profile.

The coil electrode 468 may be affixed to the lead body 462 at itsproximal end 478 and its distal end 480. While not explicitly shown, insome embodiments, the lead body 462 may include a portion that extendsbetween the proximal end 478 and the distal end 480 of the coilelectrode 468. In other embodiments, the lead body 462 may be disposedwithin one or more of the coil electrodes 476. While not explicitlyshown, the coil electrode 468 may include a lumen or passageway forreceiving a stylet or other delivery aid.

Each of the coil electrodes 476 may be formed from a round or flat(ribbon) wire, as desired. In some instances, adjacent windings of thecoil electrodes 476 may be in contact with one another while in otherinstances adjacent windings may be spread out or spaced a distance fromone another, as desired. It is contemplated that the individual coilelectrodes 476 may have the same or similar structure, or may bedifferent, as desired. For example one coil electrode may be moretightly wound than another. This is just an example.

A thin permeable membrane may be positioned over the coil 468 and/orother portions of the lead and electrode assembly 460 to inhibit tissueingrowth. In some embodiments, a single permeable membrane may surroundthe plurality of coil electrodes 476. Alternatively, or additionally,separate membranes may surround each of the coil electrodes 476individually. Coatings, such as, but not limited to expandedpolytetrafluoroethylene (ePTFE) may also be applied to the lead andelectrode assembly 460, or portions thereof, to facilitate extractionand/or to reduce tissue ingrowth. In some embodiments, one or more ofthe electrodes 466, 468, 470 may be include a high capacitive coatingsuch as, but not limited to iridium oxide (IrOx), titanium nitride(TiN), or other “fractal” coatings which may be used, for example, toimprove electrical performance. The lead and electrode assembly 460, orportions thereof, may include treatments in local areas to increaseattachment, such as, for example, along the length of the lead, near anelectrode, or at or near the distal tip, the inclusion of a roughenedsurface, a surface of different polymer or other material, or a local acoating to encourage tissue growth such as a steroid.

FIG. 5A shows a top view of another illustrative lead and electrodeassembly 500 for use with an implantable cardiac rhythm managementsystem, such as, but not limited to the S-ICD System™ from CameronHealth, Inc., and Boston Scientific Corporation described with respectto FIG. 1. While not explicitly shown, the illustrated assembly 500 maybe configured to move between a delivery configuration and an implantedconfiguration. For example, the illustrated assembly 500 may bedelivered in a generally linear configuration and placed into theoscillating configuration shown in FIG. 5A after deployment. This mayallow a smaller delivery tool to be used for insertion of the leadassembly 500. However, this is not required. It is contemplated that theillustrative lead and electrode assembly 500 may be delivered in theoscillating or curved configuration.

While not explicitly shown, the lead 502 may include a proximal end witha proximal pin which along with additional contacts serves in thisexample as an electrical contact, which may be separated by insulatingmaterial. The lead 502 may be similar in form and function to the lead302 described above. The proximal end may further include seal plugs. Aproximal plug sheath may be provided for a region near the proximal endof the lead 502. The pin, contacts, insulating material, and seal plugsmay be configured for placement inside a bore on a header of animplantable pulse generator. In some embodiments, the proximal end mayhave standard plug designs (DF-1, DF-4, etc.) for use in other devices.The lead 502 extends from this proximal configuration through anintermediate region 504 to a distal end having a proximal electrode 506,a coil electrode 508, and a distal tip electrode 510. The positioningand/or spacing of the electrodes 506, 508, 510 may be adjusted and/orreconfigured to optimize sensing and/or therapy delivery. For example,both sensing electrodes 506, 510 may be placed proximal or distal to thecoil electrode 508. This is just an example. It is contemplated that theelectrodes 506, 508, 510 may be placed beneath the skin and over theribcage of the patient. In other embodiments, the electrodes 506, 508,510 may be placed in a substernal location using an implant procedurethat may include a xiphoid or sub-xiphoid incision that allows fortunneling along the back side of the sternum. The electrodes 506, 508,510 may also be placed elsewhere as desired including for example, foruse with right sided, anterior-posterior, or other implant positions.

Lead 502 is shown for illustrative purposes, however, other designs andconfigurations including fewer, more or different electrodes 506, 508,510, or contacts, may be used. Additional design elements such asbifurcation or other splitting, paddles or other designs may be usedinstead with an anchoring device attached at the time of implant. Thelead 502 is not shown as including a passageway for a stylet to useduring introduction, however, a lumen for that purpose may be providedif desired. In the illustrative example, the lead 502 has a body thatcontains passageways having connectors therein for coupling the proximalcontacts to the coil 508, proximal electrode 506, and/or distalelectrode 510.

The distal tip electrode 510 is shown with a suture hole 512. The suturehole 512 may be coupled to a base portion 514. Other designs may beused. In some embodiments, a suture hole 512, or other fixation means,may not be required and/or may not be provided.

The coil electrode 508 have a generally oscillating shape. For example,the coil electrode 508 may include one or more oscillations 515 eachhaving a peak 516 and a valley 518. The oscillations 515 may beuniformly positioned along the longitudinal axis 520 of the assembly 500along a least a portion of the length of the coil electrode 508. In suchan instance, the peak 516 and valley 518 may have the same “height” orpeak amplitude (as measured from the longitudinal axis 520).Alternatively, or additionally, the oscillations may be shifted from thelongitudinal axis 520 such that either the peak 516 or the valley 518has a greater peak amplitude than the other along a least a portion ofthe length of the coil electrode 508. The frequency of the oscillations515 may also be varied. For example, the frequency of the oscillations515 may be increased such that there are more oscillations over asimilar length. It is contemplated that the coil electrode 508 mayinclude less than one, one, two, three, four, five, or moreoscillations, as desired. It is further contemplated that the frequencyof the oscillations 515 may be varied along the length of a coilelectrode 508. Any combination of frequency, peak amplitude, and/oroffsets from the longitudinal axis 520 may be used to arrive at thedesired shape.

It is contemplated that the coil electrode 508, or the shadow of thecoil electrode 508, may be similar in size to the coil electrode 308described above. The coil electrode 508 may have a larger surface areaand/or shadow than a typical shocking coil electrode. It is contemplatedthat increasing the surface area and/or shadow may allow thedefibrillation threshold to be lowered which may allow the canister,such as canister 12, to have a smaller profile.

A thin permeable membrane may be positioned over the coil 508 and/orother portions of the lead and electrode assembly 500 to inhibit tissueingrowth. Coatings, such as, but not limited to expandedpolytetrafluoroethylene (ePTFE) may also be applied to the lead andelectrode assembly 500, or portions thereof, to facilitate extractionand/or to reduce tissue ingrowth. In some embodiments, one or more ofthe electrodes 506, 508, 510 may be include a high capacitive coatingsuch as, but not limited to iridium oxide (IrOx), titanium nitride(TiN), or other “fractal” coatings which may be used, for example, toimprove electrical performance. The lead and electrode assembly 500, orportions thereof, may include treatments in local areas to increaseattachment, such as, for example, along the length of the lead, near anelectrode, or at or near the distal tip, the inclusion of a roughenedsurface, a surface of different polymer or other material, or a local acoating to encourage tissue growth such as a steroid.

In some embodiments, the coil electrode 508 may be delivered in astraightened, or generally linear, configuration. This may allow theassembly 500 to be implanted using a smaller profile delivery device. Inone example, the distal electrode 510 may be secured to the tissue andsubsequently the lead body 502 may be distally advanced to apply apushing force to the proximal end region of the coil electrode 508. Thismay cause the coil electrode 508 to wind back and forth, as shown inFIG. 5A, while also shortening in length. It is contemplated that thesame result may be achieved by fixing the proximal end and applying aproximal, or pulling force to the distal end of the coil electrode 508.In yet another example, the coil electrode 508 may be formed in theoscillating configuration illustrated in FIG. 5A. The coil electrode 508may be compressed into a lower profile delivery configuration throughthe application of a biasing force. For example, when the coil electrode508 are disposed within a delivery tool, the delivery tool may maintainthe coil electrode 508 in a reduced profile configuration (e.g.elongated or compressed). In yet another embodiment, the coil electrode508 may be implanted in its oscillating configuration using a deliverytool wide enough to house the coil electrode 508 in its oscillatingconfiguration.

FIG. 5B shows a top view of another illustrative lead and electrodeassembly 530 for use with an implantable cardiac rhythm managementsystem, such as, but not limited to the S-ICD System™ from CameronHealth, Inc., and Boston Scientific Corporation described with respectto FIG. 1. While not explicitly shown, the illustrated assembly 530 maybe configured to move between a delivery configuration and an implantedconfiguration. For example, the illustrated assembly 530 may bedelivered in a generally linear configuration and placed into thehelical configuration shown in FIG. 5B after deployment. This may allowa smaller delivery tool to be used for insertion of the lead assembly530. However, this is not required. It is contemplated that theillustrative lead and electrode assembly 530 may be delivered in thehelical configuration.

While not explicitly shown, the lead 532 may include a proximal end witha proximal pin which along with additional contacts serves in thisexample as an electrical contact, which may be separated by insulatingmaterial. The lead 532 may be similar in form and function to the lead302 described above. The proximal end may further include seal plugs. Aproximal plug sheath may be provided for a region near the proximal endof the lead 532. The pin, contacts, insulating material, and seal plugsmay be configured for placement inside a bore on a header of animplantable pulse generator. In some embodiments, the proximal end mayhave standard plug designs (DF-1, DF-4, etc.) for use in other devices.The lead 532 extends from this proximal configuration through anintermediate region 534 to a distal end having a proximal electrode 536,a coil electrode 538, and a distal tip electrode 540. The positioningand/or spacing of the electrodes 536, 538, 540 may be adjusted and/orreconfigured to optimize sensing and/or therapy delivery. For example,both sensing electrodes 536, 540 may be placed proximal or distal to thecoil electrode 538. This is just an example. It is contemplated that theelectrodes 536, 538, 540 may be placed beneath the skin and over theribcage of the patient. In other embodiments, the electrodes 536, 538,540 may be placed in a substernal location using an implant procedurethat may include a xiphoid or sub-xiphoid incision that allows fortunneling along the back side of the sternum. The electrodes 536, 538,540 may also be placed elsewhere as desired including for example, foruse with right sided, anterior-posterior, or other implant positions.

Lead 532 is shown for illustrative purposes, however, other designs andconfigurations including fewer, more or different electrodes 536, 538,540, or contacts, may be used. Additional design elements such asbifurcation or other splitting, paddles or other designs may be usedinstead with an anchoring device attached at the time of implant. Thelead 532 is not shown as including a passageway for a stylet to useduring introduction, however, a lumen for that purpose may be providedif desired. In the illustrative example, the lead 532 has a body thatcontains passageways having connectors therein for coupling the proximalcontacts to the coil 538, proximal electrode 536, and/or distalelectrode 540.

While not explicitly shown, the distal tip electrode 540 may include asuture hole similar to those described above. Other designs may be used.In some embodiments, a suture hole, or other fixation means, may not berequired and/or may not be provided.

The coil electrode 538 have a generally helical shape. For example, thecoil electrode 538 may be wound into a helix 542. The helix 524 may havea three dimensional shape which may facilitate better contact with thefacial plane. The coil electrode 538 forming the helix 542 may have agenerally round or a generally flat (e.g. rectangular) cross-sectionalshape, as desired. However, other cross-sectional shapes may be used.The helix 542 may have a closed pitch, or in other words, adjacentwindings may contact one another. Alternatively, the helix 542 may havean open pitch such that adjacent windings are spaced a distance from oneanother. The pitch may be uniform or varied along a length of the coilelectrode. A varied pitch may be gradual tapered changes in pitch orabrupt or step-wise changes in pitch. The helix 542 may include anynumber of windings desired, such as, but not limited to less than one,one, two, three, four, or more.

The windings of the helix 542 may be uniformly positioned (e.g.centered) along the longitudinal axis 544 of the assembly 530 along aleast a portion of the length of the coil electrode 538. Alternatively,or additionally, the helix 542 may be shifted from the longitudinal axis544 such the center of the helix 542 is offset from the longitudinalaxis 544 along a least a portion of the length of the coil electrode538. Any combination of pitch, winding diameter, and/or offsets from thelongitudinal axis 544 may be used to arrive at the desired shape.

It is contemplated that the coil electrode 538, or the shadow of thecoil electrode 538, may be similar in size to the coil electrode 308described above. The coil electrode 538 may have a larger surface areaand/or shadow than a typical shocking coil electrode. It is contemplatedthat increasing the surface area and/or shadow may allow thedefibrillation threshold to be lowered which may allow the canister,such as canister 12, to have a smaller profile.

A thin permeable membrane may be positioned over the coil 538 and/orother portions of the lead and electrode assembly 530 to inhibit tissueingrowth. Coatings, such as, but not limited to expandedpolytetrafluoroethylene (ePTFE) may also be applied to the lead andelectrode assembly 530, or portions thereof, to facilitate extractionand/or to reduce tissue ingrowth. In some embodiments, one or more ofthe electrodes 536, 538, 540 may be include a high capacitive coatingsuch as, but not limited to iridium oxide (IrOx), titanium nitride(TiN), or other “fractal” coatings which may be used, for example, toimprove electrical performance. The lead and electrode assembly 530, orportions thereof, may include treatments in local areas to increaseattachment, such as, for example, along the length of the lead, near anelectrode, or at or near the distal tip, the inclusion of a roughenedsurface, a surface of different polymer or other material, or a local acoating to encourage tissue growth such as a steroid.

In some embodiments, the coil electrode 538 may be delivered in astraightened, or generally linear, configuration. This may allow theassembly 530 to be implanted using a smaller profile delivery device. Inone example, the distal electrode 540 may be secured to the tissue andsubsequently the lead body 532 may be distally advanced to apply apushing force to the proximal end region of the coil electrode 538. Thismay cause the coil electrode 538 to coil, as shown in FIG. 5B while alsoshortening in length, as shown at arrows 418 a, 418 b. It iscontemplated that the same result may be achieved by fixing the proximalend and applying a proximal, or pulling force to the distal end of thecoil electrode 538. In yet another example, the coil electrode 538 maybe formed in the helical configuration illustrated in FIG. 5B. The coilelectrode 538 may be compressed (e.g. elongated or stretched) into alower profile delivery configuration through the application of abiasing force. For example, when the coil electrode 538 are disposedwithin a delivery tool, the delivery tool may maintain the coilelectrode 538 in a reduced profile configuration (e.g. elongated,compressed, stretched, etc.). In yet another embodiment, the coilelectrode 538 may be implanted in its helical configuration using adelivery tool wide enough to house the coil electrode 538 in its helicalconfiguration.

FIGS. 6A and 6B show a top view of another illustrative lead andelectrode assembly 600 for use with an implantable cardiac rhythmmanagement system, such as, but not limited to the S-ICD System™ fromCameron Health, Inc., and Boston Scientific Corporation described withrespect to FIG. 1. In some embodiments, the illustrated assembly 600 maybe configured to move between a collapsed or delivery configuration,shown in FIG. 6A and an expanded or implanted configuration, shown inFIG. 6B. However, it is contemplated that the illustrative lead andelectrode assembly 600 of FIG. 6A may be both the delivery configurationand the implanted configuration. Similarly, the illustrative lead andelectrode assembly 600 of FIG. 6B may be both the delivery configurationand the implanted configuration.

While not explicitly shown, the lead 602 may include a proximal end witha proximal pin which along with additional contacts serves in thisexample as an electrical contact, which may be separated by insulatingmaterial. The lead 602 may be similar in form and function to the lead302 described above. The proximal end may further include seal plugs. Aproximal plug sheath may be provided for a region near the proximal endof the lead 602. The pin, contacts, insulating material, and seal plugsmay be configured for placement inside a bore on a header of animplantable pulse generator. In some embodiments, the proximal end mayhave standard plug designs (DF-1, DF-4, etc.) for use in other devices.The lead 602 extends from this proximal configuration through anintermediate region 604 to a distal end having a proximal electrode 606,a coil electrode 608, and a distal tip electrode 610. The positioningand/or spacing of the electrodes 606, 608, 610 may be adjusted and/orreconfigured to optimize sensing and/or therapy delivery. For example,both sensing electrodes 606, 610 may be placed proximal to or distal tothe coil electrode 608. This is just an example. It is contemplated thatthe electrodes 606, 608, 610 may be placed beneath the skin and over theribcage of the patient. In other embodiments, the electrodes 606, 608,610 may be placed in a substernal location using an implant procedurethat may include a xiphoid or sub-xiphoid incision that allows fortunneling along the back side of the sternum. The electrodes 606, 608,610 may also be placed elsewhere as desired including for example, foruse with right sided, anterior-posterior, or other implant positions.

Lead 602 is shown for illustrative purposes, however, other designs andconfigurations including fewer, more or different electrodes 606, 608,610, or contacts, may be used. Additional design elements such asbifurcation or other splitting, paddles or other designs may be usedinstead with an anchoring device attached at the time of implant. Thelead 602 is not shown as including a passageway for a stylet to useduring introduction, however, a lumen for that purpose may be providedif desired. In the illustrative example, the lead 602 has a body thatcontains passageways having connectors therein for coupling the proximalcontacts to the coil 608, proximal electrode 606, and/or distalelectrode 610.

The distal tip electrode 610 is shown with a suture hole 612. The suturehole 612 may be coupled to a base portion 614. Other designs may beused. In some embodiments, a suture hole 612, or other fixation means,may not be required and/or may not be provided.

The coil electrode 608 may be formed from two or more individual coilelectrodes 616 a, 616 b. While the coil electrode 608 is illustrated asincluding two coil electrodes 616 a, 616 b, the coil electrode 608 mayincluding any number of individual coil electrodes desired, such as, butnot limited to, one, two, three, four, five, or more. The coilelectrodes 616 a, 616 b may have a generally two dimensional oscillatoryconfiguration, similar in form and function to the oscillatoryconfiguration described with respect to FIG. 5A. Alternatively, the coilelectrodes 616 a, 616 b may have a generally three dimensional helicalconfiguration, similar in form and function to the helical configurationdescribed with respect to FIG. 5B. The coil electrodes 616 a, 616 b maybe wound or coiled in opposite directions such that the coil electrodes616 a, 616 b cross at cross points 622. In some embodiments, the coilelectrodes 616 a, 616 b may be secured to one another at the crosspoints 622, although this is not required. It is contemplated that thecoil electrode 608 may include any number of cross points 622 desired,such as, but not limited to one, two, three, four, or more.

The coil electrode 608 may be affixed to the lead body 602 at itsproximal end 618 and its distal end 620. While not explicitly shown, insome embodiments, the lead body 602 may include a portion that extendsbetween the proximal end 618 and the distal end 620 of the coilelectrode 608. It is contemplated that the lead body 602 may include atelescoping feature or nested tubular members that allows the proximalend 618 and/or distal end 620 of the coil electrode 608 to be movedalong a longitudinal axis of the system 600, such as in the direction ofarrows 626 a, 626 b, shown in FIG. 6B. In other embodiments, the leadbody 602 may be disposed within one or both of the coil electrodes 616a, 616 b. While not explicitly shown, the coil electrode 608 may includea lumen or passageway for receiving a stylet or other delivery aid.

Each of the coil electrodes 616 a, 616 b may be formed from a round orflat (ribbon) wire, as desired. In some instances, adjacent windings ofthe coil electrodes 616 a, 616 b may be in contact with one anotherwhile in other instances adjacent windings may be spread out or spaced adistance from one another, as desired. It is contemplated that theindividual coil electrodes 616 a, 616 b may have the same or similarstructure, or may be different, as desired. For example one coilelectrode 616 a may be more tightly wound than the other 616 b. This isjust an example.

A thin permeable membrane may be positioned over the coil 608 and/orother portions of the lead and electrode assembly 600 to inhibit tissueingrowth. A single permeable membrane may surround both coil electrodes616 a, 616 b. Alternatively, or additionally, separate membranes maysurround each of the coil electrodes 616 a, 616 b individually.Coatings, such as, but not limited to expanded polytetrafluoroethylene(ePTFE) may also be applied to the lead and electrode assembly 600, orportions thereof, to facilitate extraction and/or to reduce tissueingrowth. In some embodiments, one or more of the electrodes 606, 608,610 may be include a high capacitive coating such as, but not limited toiridium oxide (IrOx), titanium nitride (TiN), or other “fractal”coatings which may be used, for example, to improve electricalperformance. The lead and electrode assembly 600, or portions thereof,may include treatments in local areas to increase attachment, such as,for example, along the length of the lead, near an electrode, or at ornear the distal tip, the inclusion of a roughened surface, a surface ofdifferent polymer or other material, or a local a coating to encouragetissue growth such as a steroid.

The coil electrodes 616 a, 616 b may be actuatable or expandable from adelivery configuration having a first width, shown in FIG. 6A, to animplanted configuration having a second larger width 624, as shown inFIG. 6B. For example, the second width 624 may be 2-8 times largeracross than the width of the shaft 604 and/or the non-expandedconfiguration of the coils shown by FIG. 6A.

While the embodiments shown in FIGS. 6A and 6B are described as movablebetween two different configurations, it is contemplated the lead andelectrode assembly 600 may be fixed in either arrangement. In otherwords, in some embodiments the electrodes 616 a, 616 b may be movablerelative to one another while in other embodiments, the electrodes 616a, 616 b may be in a fixed arrangement relative to one another. It iscontemplated that the coil electrode 608, in either the deliveryconfiguration or the implanted configuration, may be similar in size tothe coil electrode 308 described above. The coil electrode 608 may havea larger surface area and/or shadow than a typical shocking coilelectrode. It is contemplated that increasing the surface area and/orshadow may allow the defibrillation threshold to be lowered which mayallow the canister, such as canister 12, to have a smaller profile.

The lead and electrode assembly 600 may be actuated between the deliveryconfiguration and the implanted configuration using any number ofdeployment mechanisms. In one example, the distal electrode 610 may besecured to the tissue. Once the distal end has been secured, the leadbody 602 may be distally advanced to apply a pushing force to theproximal end 618 of the coil electrode 608. This may cause the coilelectrodes 616 a, 616 b to bias outward, as shown at arrow 624 in FIG.6B while also shortening in length, as shown at arrows 626 a, 626 b. Itis contemplated that the same result may be achieved by applying aproximal, or pulling force to the distal end 620 of the coil. In yetanother example, the coil electrodes 616 a, 616 b may be formed in theexpanded configuration illustrated in FIG. 6B. The coil electrodes 616a, 616 b may be compressed into a lower profile delivery configurationthrough the application of a biasing force. For example, when the coilelectrodes 616 a, 616 b are disposed within a delivery tool, thedelivery tool may maintain the coil electrodes 616 a, 616 b in a reducedprofile configuration.

FIG. 7 shows a top view of another illustrative lead and electrodeassembly 700 for use with an implantable cardiac rhythm managementsystem, such as, but not limited to the S-ICD System™ from CameronHealth, Inc., and Boston Scientific Corporation described with respectto FIG. 1. While not explicitly shown, the illustrated assembly 700 maybe configured to move between a delivery configuration and an implantedconfiguration. For example, the illustrated assembly 700 may bedelivered in a generally collapsed configuration (e.g. rolled) andplaced into the configuration shown in FIG. 7 after deployment. This mayallow a smaller delivery tool to be used for insertion of the leadassembly 700. However, this is not required. It is contemplated that theillustrative lead and electrode assembly 700 may be delivered through awide tunnel delivery tool with the shocking electrode 708 in a carrier.

While not explicitly shown, the lead 702 may include a proximal end witha proximal pin which along with additional contacts serves in thisexample as an electrical contact, which may be separated by insulatingmaterial. The lead 702 may be similar in form and function to the lead302 described above. The proximal end may further include seal plugs. Aproximal plug sheath may be provided for a region near the proximal endof the lead 702. The pin, contacts, insulating material, and seal plugsmay be configured for placement inside a bore on a header of animplantable pulse generator. In some embodiments, the proximal end mayhave standard plug designs (DF-1, DF-4, etc.) for use in other devices.The lead 702 extends from this proximal configuration through anintermediate region 704 to a distal end having a proximal electrode 706,a shocking electrode 708, and a distal tip electrode 710. Thepositioning and/or spacing of the electrodes 706, 708, 710 may beadjusted and/or reconfigured to optimize sensing and/or therapydelivery. For example, both sensing electrodes 706, 710 may be placedproximal or distal to the shocking electrode 708. This is just anexample. It is contemplated that the electrodes 706, 708, 710 may beplaced beneath the skin and over the ribcage of the patient. In otherembodiments, the electrodes 706, 708, 710 may be placed in a substernallocation using an implant procedure that may include a xiphoid orsub-xiphoid incision that allows for tunneling along the back side ofthe sternum. The electrodes 706, 708, 710 may also be placed elsewhereas desired including for example, for use with right sided,anterior-posterior, or other implant positions.

Lead 702 is shown for illustrative purposes, however, other designs andconfigurations including fewer, more or different electrodes 706, 708,710, or contacts, may be used. Additional design elements such asbifurcation or other splitting, paddles or other designs may be usedinstead with an anchoring device attached at the time of implant. Thelead 702 is not shown as including a passageway for a stylet to useduring introduction, however, a lumen for that purpose may be providedif desired. In the illustrative example, the lead 702 has a body thatcontains passageways having connectors therein for coupling the proximalcontacts to the shocking electrode 708, proximal electrode 706, and/ordistal electrode 710.

The distal tip electrode 710 is shown with a suture hole 712. The suturehole 712 may be coupled to a base portion 714. Other designs may beused. In some embodiments, a suture hole 712, or other fixation means,may not be required and/or may not be provided.

The shocking electrode 708 have a generally woven structure. Forexample, the shocking electrode 708 may have a woven structure,fabricated from one or more filaments 716. The filaments 716 may beembedded in, or partially embedded in a silicone carrier 718, althoughthis is not required. In some embodiments, the shocking electrode 708may be braided with one filament 716. In other embodiments, the shockingelectrode 708 may be braided with several filaments 716. In anotherembodiment, the shocking electrode 708 may be knitted or of a knottedtype. The filaments 716 may be have a generally round or a generallyflat (e.g. rectangular) cross-sectional shape, as desired. However,other cross-sectional shapes may be used. In some embodiments, eachfilament 716 may include a plurality of filaments wound or woventogether. In still another embodiment, the shocking electrode 708 may belaser cut. It is contemplated that a custom laser cut plate may be usedto achieve desired mechanical properties as well as to arrive at shapewhich reduces the defibrillation threshold. While the shocking electrode708 is illustrated as having a substantially rectangular peripheralshape, the shocking electrode 708 may take any shape desired such as,but not limited to ovular, circular, square, polygonal, etc. Theshocking electrode 708 may have a larger surface area and/or shadow thana typical shocking coil electrode. It is contemplated that increasingthe surface area and/or shadow may allow the defibrillation threshold tobe lowered which may allow the canister, such as canister 12, to have asmaller profile.

A thin permeable membrane may be positioned over the electrode 708and/or other portions of the lead and electrode assembly 700 to inhibittissue ingrowth. Coatings, such as, but not limited to expandedpolytetrafluoroethylene (ePTFE) may also be applied to the lead andelectrode assembly 700, or portions thereof, to facilitate extractionand/or to reduce tissue ingrowth. In some embodiments, one or more ofthe electrodes 706, 708, 710 may be include a high capacitive coatingsuch as, but not limited to iridium oxide (IrOx), titanium nitride(TiN), or other “fractal” coatings which may be used, for example, toimprove electrical performance. The lead and electrode assembly 700, orportions thereof, may include treatments in local areas to increaseattachment, such as, for example, along the length of the lead, near anelectrode, or at or near the distal tip, the inclusion of a roughenedsurface, a surface of different polymer or other material, or a local acoating to encourage tissue growth such as a steroid.

FIG. 8A shows a top view of another illustrative lead and electrodeassembly 800 for use with an implantable cardiac rhythm managementsystem, such as, but not limited to the S-ICD System™ from CameronHealth, Inc., and Boston Scientific Corporation described with respectto FIG. 1. While not explicitly shown, the illustrated assembly 800 maybe configured to move between a delivery configuration and an implantedconfiguration. For example, the illustrated assembly 800 may bedelivered in a generally collapsed configuration (e.g. rolled) andplaced into the configuration shown in FIG. 8 after deployment. This mayallow a smaller delivery tool to be used for insertion of the leadassembly 800. However, this is not required. It is contemplated that theillustrative lead and electrode assembly 800 may be delivered through awide tunnel delivery tool with the shocking electrode 808 in a carrier.

While not explicitly shown, the lead 802 may include a proximal end witha proximal pin which along with additional contacts serves in thisexample as an electrical contact, which may be separated by insulatingmaterial. The lead 802 may be similar in form and function to the lead302 described above. The proximal end may further include seal plugs. Aproximal plug sheath may be provided for a region near the proximal endof the lead 802. The pin, contacts, insulating material, and seal plugsmay be configured for placement inside a bore on a header of animplantable pulse generator. In some embodiments, the proximal end mayhave standard plug designs (DF-1, DF-4, etc.) for use in other devices.The lead 802 extends from this proximal configuration through anintermediate region 804 to a distal end having a proximal electrode 806,a shocking electrode 808, and a distal tip electrode 810. Thepositioning and/or spacing of the electrodes 806, 808, 810 may beadjusted and/or reconfigured to optimize sensing and/or therapydelivery. For example, both sensing electrodes 806, 810 may be placedproximal to or distal to the shocking electrode 808. This is just anexample. It is contemplated that the electrodes 806, 808, 810 may beplaced beneath the skin and over the ribcage of the patient. In otherembodiments, the electrodes 806, 808, 810 may be placed in a substernallocation using an implant procedure that may include a xiphoid orsub-xiphoid incision that allows for tunneling along the back side ofthe sternum. The electrodes 806, 808, 810 may also be placed elsewhereas desired including for example, for use with right sided,anterior-posterior, or other implant positions.

Lead 802 is shown for illustrative purposes, however, other designs andconfigurations including fewer, more or different electrodes 806, 808,810, or contacts, may be used. Additional design elements such asbifurcation or other splitting, paddles or other designs may be usedinstead with an anchoring device attached at the time of implant. Thelead 802 is not shown as including a passageway for a stylet to useduring introduction, however, a lumen for that purpose may be providedif desired. In the illustrative example, the lead 802 has a body thatcontains passageways having connectors therein for coupling the proximalcontacts to the shocking electrode 808, proximal electrode 806, and/ordistal electrode 810.

The distal tip electrode 810 is shown with a suture hole 812. The suturehole 812 may be coupled to a base portion 814. Other designs may beused. In some embodiments, a suture hole 812, or other fixation means,may not be required and/or may not be provided.

The shocking electrode 808 may be a printed circuit patch on a liquidcrystal polymer 818. The shocking electrode 808 may include a platinum,gold, or other noble trace 816 positioned on the liquid crystal polymer.The trace 816 or circuit may take any pattern desired and may beselected to optimize the therapy. For example, the trace 816 may be acontinuous trace which winds back and forth over the surface of theliquid crystal polymer 818. It is further contemplated that theperipheral shape of the shocking electrode 808 may also be selected toreduce the defibrillation threshold. While the shocking electrode 808 isillustrated as having a substantially oval peripheral shape, theshocking electrode 708 may take any shape desired such as, but notlimited to rectangular, circular, square, polygonal, tear drop, etc. Theshocking electrode 808 may have a larger surface area and/or shadow thana typical shocking coil electrode. It is contemplated that increasingthe surface area and/or shadow may allow the defibrillation threshold tobe lowered which may allow the canister, such as canister 12, to have asmaller profile.

A thin permeable membrane may be positioned over the shocking electrode808 and/or other portions of the lead and electrode assembly 800 toinhibit tissue ingrowth. Coatings, such as, but not limited to expandedpolytetrafluoroethylene (ePTFE) may also be applied to the lead andelectrode assembly 800, or portions thereof, to facilitate extractionand/or to reduce tissue ingrowth. In some embodiments, one or more ofthe electrodes 806, 808, 810 may be include a high capacitive coatingsuch as, but not limited to iridium oxide (IrOx), titanium nitride(TiN), or other “fractal” coatings which may be used, for example, toimprove electrical performance. The lead and electrode assembly 800, orportions thereof, may include treatments in local areas to increaseattachment, such as, for example, along the length of the lead, near anelectrode, or at or near the distal tip, the inclusion of a roughenedsurface, a surface of different polymer or other material, or a local acoating to encourage tissue growth such as a steroid.

FIGS. 8B-8E show top view of alternative shocking electrodes 808 thatmay be used with the illustrative lead and electrode assembly 800described above. The shocking electrodes 808 illustrated in FIGS. 8A-8Eshould not be considered to be inclusive of all possible arrangements ofthe printed circuit patch but rather examples of some possibleconfigurations. The configurations of printed traces 816 and electrodes820 are endless and may be highly customized to achieve a desireddefibrillation threshold. FIG. 8B illustrates a shocking electrode 808that includes a plurality of traces 816 fanning out from a central areaof the liquid crystal polymer 818, in a similar manner to the veins of aleaf. A printed electrode 820 may be positioned at the end of all orsome of the traces 816. The printed electrodes 820 may vary in shape andsize as desired.

FIG. 8C illustrates a shocking electrode 808 that includes a pluralityof traces 816. Each trace 816 may have a shape which mirrors theperipheral shape of the liquid crystal polymer 818. The traces 816 maybe spaced a distance from one another at regular or irregular intervals.The traces 816 may get progressively smaller towards the center of theliquid crystal polymer 818. In some instances, the traces 816 maygenerally resemble a loop-type fingerprint. The number and/or size ofthe traces 816 may vary, as desired.

FIG. 8D illustrates a shocking electrode 808 that include a centrallylocated electrode 820 and a plurality of electrodes 820 positioned abouta perimeter of the liquid crystal polymer 818. The electrodes 820 may beconnected through a series of traces 816. The electrodes 820 may vary inshape, size, and/or positioning as desired.

FIG. 8E a shocking electrode 808 having a bulbous shape. The shockingelectrode 808 may include a plurality of electrodes 820. In someinstances, the electrodes 820 may be sized and shaped to mirror aperimeter of the liquid crystal polymer 818. The electrodes 820 may beconnected to one or more traces 816. The electrodes 820 may vary inshape, size, and/or positioning as desired.

FIGS. 9A and 9B show a top view of another illustrative lead andelectrode assembly 900 for use with an implantable cardiac rhythmmanagement system, such as, but not limited to the S-ICD System™ fromCameron Health, Inc., and Boston Scientific Corporation described withrespect to FIG. 1. In some embodiments, the illustrated assembly 900 maybe configured to move between a collapsed or delivery configuration,shown in FIG. 9A and an expanded or implanted configuration, shown inFIG. 9B. However, it is contemplated that the illustrative lead andelectrode assembly 900 of FIG. 9A may be both the delivery configurationand the implanted configuration. Similarly, the illustrative lead andelectrode assembly 900 of FIG. 9B may be both the delivery configurationand the implanted configuration.

While not explicitly shown, the lead 902 may include a proximal end witha proximal pin which along with additional contacts serves in thisexample as an electrical contact, which may be separated by insulatingmaterial. The lead 902 may be similar in form and function to the lead302 described above. The proximal end may further include seal plugs. Aproximal plug sheath may be provided for a region near the proximal endof the lead 902. The pin, contacts, insulating material, and seal plugsmay be configured for placement inside a bore on a header of animplantable pulse generator. In some embodiments, the proximal end mayhave standard plug designs (DF-1, DF-4, etc.) for use in other devices.The lead 902 extends from this proximal configuration through anintermediate region 904 to a distal end having a proximal electrode 906,a coil electrode 908, and a distal tip electrode 910. The positioningand/or spacing of the electrodes 906, 908, 910 may be adjusted and/orreconfigured to optimize sensing and/or therapy delivery. For example,both sensing electrodes 906, 910 may be placed proximal or distal to thecoil electrode 908. This is just an example. It is contemplated that theelectrodes 906, 908, 910 may be placed beneath the skin and over theribcage of the patient. In other embodiments, the electrodes 906, 908,910 may be placed in a substernal location using an implant procedurethat may include a xiphoid or sub-xiphoid incision that allows fortunneling along the back side of the sternum. The electrodes 906, 908,910 may also be placed elsewhere as desired including for example, foruse with right sided, anterior-posterior, or other implant positions.

Lead 902 is shown for illustrative purposes, however, other designs andconfigurations including fewer, more or different electrodes 906, 908,910, or contacts, may be used. Additional design elements such asbifurcation or other splitting, paddles or other designs may be usedinstead with an anchoring device attached at the time of implant. Thelead 902 is not shown as including a passageway for a stylet to useduring introduction, however, a lumen for that purpose may be providedif desired. In the illustrative example, the lead 902 has a body thatcontains passageways having connectors therein for coupling the proximalcontacts to the coil 908, proximal electrode 906, and/or distalelectrode 910.

The distal tip electrode 910 is shown with a suture hole 912. The suturehole 912 may be coupled to a base portion 914. Other designs may beused. In some embodiments, a suture hole 912, or other fixation means,may not be required and/or may not be provided.

The coil electrode 908 may be formed from two or more individualelectrodes 916 a, 916 b. In some embodiments, the electrodes 916 a, 916b may be coil electrodes. In other embodiments, the electrodes 916 a,916 b may be other electrically active members, such as, but not limitedto, struts. While the coil electrode 908 is illustrated as including twoelectrodes 916 a, 916 b, the coil electrode 908 may including any numberof individual electrodes desired, such as, but not limited to, one, two,three, four, five, or more. Further, in either configuration, coilelectrodes 916 a, 916 b may be positioned close to one another (e.g.touching) or spaced a distance, as desired. The coil electrode 908 maybe affixed to the lead body 902 at its proximal end 920 and its distalend 922. As shown in FIG. 9B, in some embodiments, the lead body 902 mayinclude a portion 926 that extends between the proximal end 920 and thedistal end 922 of the coil electrode 908. It is contemplated that thelead body 902 may include a telescoping feature or nested tubularmembers that allows the proximal end 920 and/or distal end 922 of thecoil electrode 908 to be moved along a longitudinal axis of the system900, such as in the direction of arrows 930 a, 930 b, shown in FIG. 9B.In other embodiments, the lead body 902 may be disposed within one orboth of the electrodes 916 a, 916 b. While not explicitly shown, thecoil electrode 908 may include a lumen or passageway for receiving astylet or other delivery aid.

Each of the electrodes 916 a, 916 b may be formed from a round or flat(ribbon) wire, as desired. The wires may be relatively straight orcoiled, as desired. In some instances, adjacent windings of theelectrodes 916 a, 916 b may be in contact with one another while inother instances adjacent windings may be spread out or spaced a distancefrom one another, as desired. It is contemplated that the individualcoil 916 a, 916 b may have the same or similar structure, or may bedifferent, as desired. For example one electrode 916 a may be moretightly wound than the other 916 b. This is just an example.

A thin permeable membrane may be positioned over the shocking electrode908 and/or other portions of the lead and electrode assembly to inhibittissue ingrowth. A single permeable membrane may surround bothelectrodes 916 a, 916 b. Alternatively, or additionally, separatemembranes may surround each of the electrodes 916 a, 916 b individually.Coatings, such as, but not limited to expanded polytetrafluoroethylene(ePTFE) may also be applied to the lead and electrode assembly 900, orportions thereof, to facilitate extraction and/or to reduce tissueingrowth. In some embodiments, one or more of the electrodes 906, 908,910 may be include a high capacitive coating such as, but not limited toiridium oxide (IrOx), titanium nitride (TiN), or other “fractal”coatings which may be used, for example, to improve electricalperformance. The lead and electrode assembly 900, or portions thereof,may include treatments in local areas to increase attachment, such as,for example, along the length of the lead, near an electrode, or at ornear the distal tip, the inclusion of a roughened surface, a surface ofdifferent polymer or other material, or a local a coating to encouragetissue growth such as a steroid.

The electrodes 916 a, 916 b may be actuatable or expandable from adelivery configuration having a first width 924, shown in FIG. 9A, to animplanted configuration having a second larger width 928, as shown inFIG. 9B. While the embodiments shown in FIGS. 9A and 9B are described asmovable between two different configurations, it is contemplated thelead and electrode assembly 900 may be fixed in either arrangement. Inother words, in some embodiments the electrodes 916 a, 916 b may bemovable relative to one another while in other embodiments, theelectrodes 916 a, 916 b may be in a fixed arrangement relative to oneanother. It is contemplated that the coil electrode 908, in either thedelivery configuration or the implanted configuration, may be similar insize to the coil electrode 308 described above. The coil electrode 908may have a larger surface area and/or shadow than a typical shockingcoil electrode. It is contemplated that increasing the surface areaand/or shadow may allow the defibrillation threshold to be lowered whichmay allow the canister, such as canister 12, to have a smaller profile.

The lead and electrode assembly 900 may be actuated between the deliveryconfiguration and the implanted configuration using any number ofdeployment mechanisms. In one example, the distal electrode 910 may besecured to the tissue. Once the distal end has been secured, the leadbody 902 may be distally advanced to apply a pushing force to theproximal end 920 of the coil electrode 908 using, for example apush-pull member 918. This may cause the coil electrodes 916 a, 916 b tobias outward, for example in directions 932 a, 932 b, shown in FIG. 9Bwhile also shortening in length, as shown at arrows 930 a, 930 b. It iscontemplated that the same result may be achieved by applying aproximal, or pulling force to the distal end 922 of the coil 908 usingthe push-pull member 918. In yet another example, the coil electrodes916 a, 916 b may be formed in the expanded configuration illustrated inFIG. 9B. The coil electrodes 916 a, 916 b may be compressed into a lowerprofile delivery configuration through the application of a biasingforce. For example, when the coil electrodes 916 a, 916 b are disposedwithin a delivery tool, the delivery tool may maintain the coilelectrodes 916 a, 916 b in a reduced profile configuration.

FIG. 10 shows a top view of another illustrative lead and electrodeassembly 1000 for use with an implantable cardiac rhythm managementsystem, such as, but not limited to the S-ICD System™ from CameronHealth, Inc., and Boston Scientific Corporation described with respectto FIG. 1. The lead and electrode assembly 1000 may include a first leadand electrode assembly 1001 a and a second lead and electrode assembly1001 b. While the assembly 1000 is described as including two lead andelectrode assemblies 1001 a, 1001 b, it is contemplated that theassembly 1000 may include any number of assemblies desired, such as, butnot limited to one, two, three, four, or more. In some embodiments, thelead and electrode assembly 1000 may be configured to place a first leadand electrode assembly 1001 a along a first side of the sternum and theother lead and electrode assembly 1001 b on the opposite side of thesternum, although this is not required.

While not explicitly shown, each assembly 1001 a, 1001 b may include alead 1002 a, 1002 b including a proximal end with a proximal pin whichalong with additional contacts serves in this example as an electricalcontact, which may be separated by insulating material. The leads 1002a, 1002 b may be similar in form and function to the lead 302 describedabove. The proximal end may further include seal plugs. A proximal plugsheath may be provided for a region near the proximal end of the leads1002 a, 1002 b. The pin, contacts, insulating material, and seal plugsmay be configured for placement inside a bore on a header of animplantable pulse generator. In some embodiments, the proximal end mayhave standard plug designs (DF-1, DF-4, etc.) for use in other devices.The leads 1002 a, 1002 b extend from this proximal configuration throughan intermediate regions 1004 a, 1004 b to a distal end having a proximalelectrode 1006 a, 1006 b, a coil electrode 1008 a, 1008 b, and a distaltip electrode 1010 a, 1010 b. The positioning and/or spacing of theelectrodes 1006 a, 1006 b, 1008 a, 1008 b, 1010 a, 1010 b may beadjusted and/or reconfigured to optimize sensing and/or therapydelivery. For example, both sensing electrodes 1006 a, 1006 b, 1010 a,1010 b may be placed proximal to or distal to the coil electrode 1008 a,1008 b. In other embodiments, only one of the assemblies may includesensing electrodes. These is just an example. It is contemplated thatthe electrodes 1006 a, 1006 b, 1008 a, 1008 b, 1010 a, 1010 b may beplaced beneath the skin and over the ribcage of the patient. In otherembodiments, the electrodes 1006 a, 1006 b, 1008 a, 1008 b, 1010 a, 1010b may be placed in a substernal location using an implant procedure thatmay include a xiphoid or sub-xiphoid incision that allows for tunnelingalong the back side of the sternum. The electrodes 1006 a, 1006 b, 1008a, 1008 b, 1010 a, 1010 b may also be placed elsewhere as desiredincluding for example, for use with right sided, anterior-posterior, orother implant positions.

Lead 1002 a, 1002 b is shown for illustrative purposes, however, otherdesigns and configurations including fewer, more or different electrodes1006 a, 1006 b, 1008 a, 1008 b, 1010 a, 1010 b, or contacts, may beused. Additional design elements such as bifurcation or other splitting,paddles or other designs may be used instead with an anchoring deviceattached at the time of implant. The lead 1002 a, 1002 b is not shown asincluding a passageway for a stylet to use during introduction, however,a lumen for that purpose may be provided if desired. In the illustrativeexample, the lead 1002 a, 1002 b has a body that contains passagewayshaving connectors therein for coupling the proximal contacts to the coil1008 a, 1008 b, proximal electrode 1006 a, 1006 b, and/or distalelectrode 1010 a, 1010 b.

The distal tip electrode 1010 a, 1010 b is shown with a suture hole 1012a, 1012 b. The suture hole 1012 a, 1012 b may be coupled to a baseportion 1014 a, 1014 b. Other designs may be used. In some embodiments,a suture hole 1012 a, 1012 b, or other fixation means, may not berequired and/or may not be provided.

These assemblies 1001 a, 1001 b may be designed into one singleelectrode with a yolk feature and single terminal for connection to thecanister. For example, the two coil electrodes 1008 a, 1008 b may beformed as a single electrode having a “V” or “Y” configuration.Alternatively, the assemblies 1001 a, 1001 b may include two completelyseparate electrodes or assemblies that plug into a dual chamber headereach with their own terminal. In yet another embodiment, the assemblies1001 a, 1001 b may also use an adaptor in which each assembly 1001 a,1001 b may be plugged into. The adaptor may then be plugged into thecanister with a single terminal. In another embodiment, one electrodemay be built with an optional “second electrode” port integrated intothe lead body (similar to a built in “Y” adaptor). This may allow theuser may choose to add a second electrode to the patient by plugging itinto this port. These configurations may allow the coil electrodes 1008a, 1008 b to have a larger surface area and/or shadow than a typicalshocking coil electrode. It is contemplated that increasing the surfacearea and/or shadow may allow the defibrillation threshold to be loweredwhich may allow the canister, such as canister 12, to have a smallerprofile.

While not explicitly shown, the coil electrodes 1008 a, 1008 b mayinclude a lumen or passageway for receiving a stylet or other deliveryaid. A thin permeable membrane may be positioned over the coil 1008 a,1008 b and/or other portions of the lead and electrode assemblies 1001a, 1001 b to inhibit tissue ingrowth. A single permeable membrane maysurround both electrodes 1008 a, 1008 b. Alternatively, or additionally,separate membranes may surround each of the electrodes 1008 a, 1008 bindividually. Coatings, such as, but not limited to expandedpolytetrafluoroethylene (ePTFE) may also be applied to the lead andelectrode assembly 1001 a, 1001 b, or portions thereof, to facilitateextraction and/or to reduce tissue ingrowth. In some embodiments, one ormore of the electrodes 1006 a, 1006 b, 1008 a, 1008 b, 1010 a, 1010 bmay be include a high capacitive coating such as, but not limited toiridium oxide (IrOx), titanium nitride (TiN), or other “fractal”coatings which may be used, for example, to improve electricalperformance. The lead and electrode assembly 1001 a, 1001 b, or portionsthereof, may include treatments in local areas to increase attachment,such as, for example, along the length of the lead, near an electrode,or at or near the distal tip, the inclusion of a roughened surface, asurface of different polymer or other material, or a local a coating toencourage tissue growth such as a steroid.

FIG. 11 shows an illustrative prior art electrode introducer tool. Theillustrative prior art tool 1100 includes a bullet-shaped tunneling tip1102 at the end of a stiff shaft 1104 made, for example, of a medicalgrade metal such as stainless steel. At the proximal end, there is agripping portion 1104 and a port 1108. The gripping portion 1106 isprovided for ergonomics but does not provide any indication of therotational placement of the shaft 1104 and/or tip 1102 (unlike severalillustrative examples shown below).

The tip 1102 may include a hook or a suture hole, for example, to allowit to be secured to a lead for implantation. For example, in some priormethods, the tunneling tool would be used to tunnel from a xiphoidincision to an incision at the left axilla and, once the tunneling tooltip 1102 is accessible at the left axillary incision, a distal tip of alead would be sutured thereto, in order that the lead could be pulledinto the tunnel formed during advancement from the xiphoid incision tothe left axillary incision as the tool 1100 is withdrawn. A suture holeor other attachment feature may be used in some of the illustrativeexamples that follow.

In some disclosures of a device as in FIG. 11, the proximal port 1108may be used to infuse or inject analgesic, antibiotic, or othersubstance, to prevent patient pain or infection. For example, somedescriptions suggested that lidocaine could be provided via the port1108 for infusion through a lumen extending to the suture hole at thetip 1102 (see, for example, U.S. Pat. No. 8,157,813). However, the lumenso described was not suggested as providing an avenue for implantationof the electrical lead itself, in contrast to several examples thatfollow.

FIGS. 12A-12C show an illustrative tunneling tool. The tool 1200 isshown with a distal tunneling tip 1202, proximal to which there is anelongated, rigid shaft 1204; the shaft 1204 may be malleable to fit aparticular patient anatomy if desired, and may be made, for example, ofstainless steel or other suitable biocompatible material. While the tool1200 is shown as a straight tunneling tool, it may come in a curvedconfiguration instead. A coating of slippery material, for example, maybe provided over the tunneling tip 1202 and/or shaft 1204.

A proximal handle is shown at 1206 and may include a proximal port at1201 for infusion of a liquid, fluid or gas, if desired. The crosssection at FIG. 12B shows a generally circular profile, though othershapes may be used if desired. An alternative cross section is shown atFIG. 12C, indicating this time a shaft 1220 having a lumen therein at1222. The lumen 1222 may be sized to receive a guidewire or stylet toallow tracking or additional stiffness during tunneling. If desired, thelumen 1222 may be sized to receive a lead for implantation. In someexamples, the lumen 1222 is sized to receive a lead having a collapsiblesection which may include an electrode, such as shown in severalexamples above.

Alternatively, during insertion of a tool as shown in FIGS. 12A-12B tocreate a tunnel in a patient for lead implantation, a sheath, such as atearable sheath, may be placed over the tunneling tool 1200. Once thedesired tunnel is made, the sheath would be held in place as thetunneling tool 1200 is removed, and the lead would be inserted into thesheath to a desired position. The sheath would then be removed by, forexample, tearing it along a line of preferential tearing such as aperforation.

This illustration is somewhat similar to that of FIG. 11 in certainrespects, however there are significant differences. First, the shaft1204 in FIG. 12 is intended to be larger than that of the moreconventional tool shown in FIG. 11. For example, the tool in FIG. 11 mayhave an outer diameter at the tip and shaft in the range of about 3.2millimeters, while the device in FIG. 12 may have an outer diameter of 4millimeters up to about 10 millimeters. In another respect, the lumen1222 shown for FIG. 12 may be used for passing through a second device,such as a guidewire, stylet or the lead that is being implanted.

The device of FIGS. 12A-12C may be used in a method such as detailedabove in FIG. 2. For example, the tunneling tip 1202 may be advancedthrough an incision to a desired location, such that a tunnel is createdto that desired location which may be subcutaneous, substernal, oranother location to which lead placement is desired. The tool may thenbe removed and a lead placed. In an alternative, the lead may becontained in a lumen such as lumen 1222 in the tunneling tool duringtunneling, or may be advanced through the lumen 1222 after tunneling iscomplete. The proximal handle 1206 may include a port at location 1210or as shown at 1212, through which the lead can exit. As the tool 1200is removed, the lead may be held in place for removal in an“over-the-wire” manner. If the lead has a collapsible electrode such asone shown in various examples above, the collapsible electrode may thenbe expanded after the tool 1200 is removed.

FIGS. 13A-13D show another illustrative tunneling tool. Here, the tool1300 has a wide projection near its distal tunneling tip 1302. Theprojection is shown at 1304 along the distal end of the shaft 1306. Ifdesired, sharpened cutting edges may be provided on one or more edges1308 of the projection 1304 including, for example, the leading(distal-facing) edges, as shown, or one the trailing (proximal facing)edges (not shown), as well as the outward facing edges tangent to theaxis of the tool 1300. The cutting edges 1308 may be provided to make iteasier for the user to dissect tissue and/or separate tissue layersduring tunneling.

The projection 1304 has a width that is greater than its thickness, ashighlighted in the cross section at FIG. 13B, while the main shaft maybe generally circular as shown at 1306 in FIG. 13C, or may have anyother suitable shape such as polygonal or oval, if desired. The handleof the tool 1300 at its proximal end may include a flattened portion asshown at 1310. By flattened portion, no specific method of manufacturingis intended to be conveyed; rather, the intend of the descriptive termis to indicate that there is a portion having a width that is greaterthan its thickness, with the width of the flattened portion 1310 alignedwith the width of the projection 1304, as shown in FIG. 13A. Theflattened portion 1310 can thus be used by an implanter to determine theorientation of the projection relative to the tissue layers of thepatient quickly and without having to palpate the patient's skin.

As highlighted in FIG. 13D, the tool 1300 may include a lumen 1322 thatextends through the shaft 1306 and/or projection. The lumen 1322 may beopen at the distal tip 1302, if desired. The lumen 1322 may be sized toreceive a guidewire or stylet to allow tracking or additional stiffnessduring tunneling. If desired, the lumen 1322 may be sized to receive alead for implantation. In some examples, the lumen 1322 is sized toreceive a lead having a collapsible section which may include anelectrode, such as shown in several examples above.

The device of FIGS. 13A-13D may be used in a method such as detailedabove in FIG. 2. For example, the tunneling tip 1302 may be advancedthrough an incision to a desired location, such that a tunnel is createdto that desired location which may be subcutaneous, substernal, oranother location to which lead placement is desired. The tunnel socreated may be wider than it is thick, as defined in part by theprojection 1304; generally the aim may be to separate tissue layers asopposed to actually cutting tissue itself. The physician/user may usethe flattened portion 1310 of the handle to determine the orientation ofprojection 1304 during tunneling. The tool may then be removed and alead placed. In an alternative, the lead may be contained in a lumensuch as lumen 1322 in the tunneling tool 1300 during tunneling, or maybe advanced through the lumen 1322 after tunneling is complete. Theproximal handle may include a port (not shown) through which theproximal end of the lead can exit. As the tool 1300 is removed, the leadmay be held in place for removal in an “over-the-wire” manner, keepingat least a portion of the lead within the patient and/or at a desiredlocation in the patient. If the lead has a collapsible electrode such asone shown in various examples above, the collapsible electrode may thenbe expanded after the tool 1300 is removed.

FIGS. 14A-14C show another illustrative tunneling tool. The tool 1400includes a distal tunneling tip 1402, and a shaft 1404 extending theretofrom a handle (not shown). The shaft 1404 may have a profile as shown inFIG. 14B, and may include a lumen 1412 therethrough as shown by FIG.14C. The handle (not shown) may include a flattened section/elementhaving a similar utility to element 1310 in FIG. 13A.

The device of FIGS. 14A-14C may be used in a method such as detailedabove in FIG. 2. For example, the tunneling tip 1402 may be advancedthrough an incision to a desired location, such that a tunnel is createdto that desired location which may be subcutaneous, substernal, oranother location to which lead placement is desired. The tunnel socreated may be wider than it is thick, as defined in part by the profileshown at 1404 in FIG. 14B. Again, the aim may be to separate tissuelayers as opposed to actually cutting tissue itself. The physician/usermay use the flattened portion of the handle to determine the orientationof shaft 1404 during tunneling. The tool may then be removed and a leadplaced. In an alternative, the lead may be contained in a lumen such aslumen 1412 in the tunneling tool 1400 during tunneling, or may beadvanced through the lumen 1412 after tunneling is complete. Theproximal handle may include a port (not shown) through which the leadproximal end can exit. As the tool 1400 is removed, the lead may be heldin place for removal in an “over-the-wire” manner, keeping at least aportion of the lead within the patient and/or at a desired location inthe patient. If the lead has a collapsible electrode such as one shownin various examples above, the collapsible electrode may then beexpanded after the tool 1400 is removed.

FIGS. 15A-15E show an illustrative tunneling tool having an inflatableelement. In this example, the tunneling tool 1500 includes a distaltunneling tip 1502 with an inflatable balloon 1504 mounted proximallythereof on a shaft 1506. The balloon 1504 may at least initially bewrapped on the shaft 1506 to keep a reduced profile during initialtunneling (the width of the balloon 1504 shown in FIG. 15A isexaggerated for ease of visualization). One or several lumens may beprovided within the shaft 1506 including, for example, an inflationlumen and a device lumen shown at 1508; the device lumen 1508 mayinstead be omitted if desired.

A handle is also shown at 1510 with details highlighted at FIG. 15B. Aflattened portion is shown in FIG. 15B with a central piece having oneor more lumens therein and wings 1514. The wings 1514, as detailedfurther below, may align with the width and/or cutting edges (ifprovided) on the balloon 1504 when the balloon is fully inflated.

Inflation is controlled at a first port 1514 which may include apressure gage as shown at 1516 to determine and control inflationpressure. Inflation may be provided using any suitable gas or liquid;typically a sterile saline may be used for inflation. If desired, astylet or guidewire may be provided as well, with handle 1520 formanipulating a distal tip 1522. The stylet or guidewire may be used toguide the tool 1500 to a desired location and/or may provide addedstiffness during insertion.

FIG. 15C shows the balloon 1504 in an inflated state. The balloon 1504is preferably a non-complaint balloon which, when inflated to selectedpressure, will assume a pre-defined shape. Various materials are knownfor non-compliant balloon construction, including balloons forangioplasty procedures; example materials may include nylon andpolyethylene terephthalate. Some examples are discussed in U.S. Pat.Nos. 5,348,538 and 5,714,110; shape for the balloon may be created asdiscussed in the '538 patent.

The balloon in a fully inflated state is shown at 1540 in FIG. 15C, withleading edge 1544 and trailing edge 1546, with a central member shown at1542 extending therethrough. FIG. 15D shows a section view of theballoon 1540, with this variant 1560 having a greater width thanthickness. The central member 1564 may include a lumen (as shown), or itmay be solid. One or more of the central member 1564 or the main shaft1506 may be formed of a reinforced polymeric tube (such as a catheterhaving a mesh, braid, coil or other support embedded or coextrudedtherein), or of a hypotube, or of any other suitable structure andmaterial.

FIG. 15E shows another variant in which the balloon 1570 may be morecircular in outer profile, with the central member 1574 again beingeither solid (as shown) or having a lumen therein.

The balloon 1504 may include cutting edges as highlighted at 1562 inFIG. 15D and 1572 in FIG. 15E. Methods and materials for making cuttingballoon catheters may be drawn from intravascular devices. Someillustrative examples are shown in U.S. Pat. Nos. 7,070,576, 7,632,288,7,758,604, 7,976,557, and 8,491,615, the disclosures of which areincorporated herein by reference. Other designs may be used in thepresent invention, as the intent is not to limit to any specificmaterial or structure for the cutting balloon design.

The device of FIGS. 15A-15E may be used in a method such as detailedabove in FIG. 2. For example, the tunneling tip 1502 may be advancedthrough an incision to a desired location, with or without use of aguidewire or stylet 1520/1522. A preliminary tunnel is thus created to adesired location which may be subcutaneous, substernal, or anotherlocation to which lead placement is desired. Next, the inflatableelement, such as balloon 1504, can be inflated via the inflation port1514, to expand the tunnel in a preferred manner using, for example, awide, flat balloon (FIG. 15D) or a round balloon (FIG. 15E). This may bea single step for dissection, or the inflatable element, such as balloon1504, may be inflated, deflated, repositioned, and inflated again, tocontinue to create a desired space for the lead. Alternatively, theinflatable element, such as balloon 1504, may be expanded and kept in anexpanded configuration while it is moved to create a desired space forthe lead. Either way, the aim may be to separate tissue layers asopposed to actually cutting tissue itself.

The physician/user may use the flattened portion of the handle todetermine the orientation of shaft 1506 during tunneling. The tool may1500 then be removed after the balloon 1504 is deflated, and a leadplaced. In an alternative, the lead may be contained in a lumen such aslumen 1508 in the tunneling tool 1500 during tunneling, or may beadvanced through the lumen 1508 after tunneling is complete. Theproximal handle may include a port through which the lead proximal endcan exit. As the tool 1500 is removed, the lead may be held in place forremoval in an “over-the-wire” manner, keeping at least a portion of thelead within the patient and/or at a desired location in the patient. Ifthe lead has a collapsible electrode such as one shown in variousexamples above, the collapsible electrode may then be expanded after thetool 1500 is removed.

FIGS. 16A-16B show another illustrative tunneling tool having aninflatable element. The tunneling tool 1600 is shown with a tunnelingtip 1602 that, in this instance, has an open ended lumen therethrough.An expandable member is shown as inflated balloon 1604 through which acentral member extends. Though not included in the embodiment shown inFIGS. 16A-16B, the balloon 1604 may include cutting edges if desired.The main shaft 1606 of the device extends to a handle 1608. The handleis shown having a flatter, wide portion at 1608, which can be used as aguide to maintain the desired tissue plane when inflating or otherwiseusing the balloon 1604 for tissue dissection/separation. In addition,the handle includes a first device port at 1610, an inflation port at1612, a grip at 1614, and a second device port at 1616.

The first and second device ports 1610, 1616 may access the same ordifferent lumens. In the illustration of FIG. 16A, two alternative waysof inserting an electrode are highlighted—the electrode proximal end isshown as a plug 1622A, exiting first device port 1610; as analternative, the electrode proximal end may be at plug 1622B, exitingthe second device port 1616. In another example, port 1616 may be usedto insert a guidewire or stylet during insertion of the tool 1600 to adesired location in the patient, after which the guidewire or stylet maybe removed and replaced with an electrode 1620 inserted through eitherof the device ports 1610, 1616.

The cross section at FIG. 16B illustrates the main shaft 1606 comprisesan inner tubular member 1618, with a device lumen shown at 1630, andinflation lumen at 1632. A coaxial cross section is shown, however, aside-by-side configuration may be used instead if desired. As is knownin the catheter arts, the outer shaft 1606 or inner tubular member 1618may be formed for stiffness and steerability, with the inner tubularmember 1618 possibly having a slippery innermost layer and an outerlayer adapted for secure attachment to the balloon, with a tie layertherebetween. The outer shaft 1606 may include a braided or othersupport member within a polymeric extrusion, or may include or be formedof a hypotube. Additional support structures to provided added stiffnessand pushability, such as a core wire or core wires, may be included aswell. Some balloon angioplasty details may be found in U.S. Pat. No.6,102,890 and the additional patents and references cited therein.

The device of FIGS. 16A-16B may be used in a method such as detailedabove in FIG. 2. For example, the tunneling tip 1602 may be advancedthrough an incision to a desired location, with or without use of aguidewire or stylet. A preliminary tunnel is thus created to a desiredlocation which may be subcutaneous, substernal, or another location towhich lead placement is desired. Next, the inflatable element, such asballoon 1604, can be inflated via the inflation port 1612, to expand thetunnel in a preferred manner using, for example, a wide, flat balloon(see again FIG. 15D) or a round balloon (see again FIG. 15E). This maybe a single step for dissection, or the inflatable element, such asballoon 1604, may be inflated, deflated, repositioned, and inflatedagain, to continue to create a desired space for the lead.Alternatively, the inflatable element, such as balloon 1604, may beexpanded and kept in an expanded configuration while it is moved tocreate a desired space for the lead. Either way, the aim may be toseparate tissue layers as opposed to actually cutting tissue itself.

The physician/user may use the flattened portion of the handle 1614 todetermine the orientation of shaft 1606 and balloon 1604 duringtunneling. The tool 1600 may then be removed after the balloon 1604 isdeflated, and a lead placed. In an alternative, the lead may becontained in a lumen such as device lumen 1630 in the tunneling tool1600 during tunneling, or may be advanced through the lumen 1630 aftertunneling is complete, with the proximal end 1622A/1622B of the lead1620 exiting either of ports 1610 or 1616. As the tool 1600 is removed,the lead may be held in place for removal in an “over-the-wire” manner,keeping at least a portion of the lead within the patient and/or at adesired location in the patient. If the lead has a collapsible electrodesuch as one shown in various examples above, the collapsible electrodemay then be expanded after the tool 1600 is removed.

It should be noted that, if desired, a “rapid-exchange” approach may beused in which a side-by-side lumen construction on the main shaft 1606includes a device lumen having a tearable or frangible wall, or a slitor channel, through which the lead 1620 may exit the main shaft 1606 asthe tool 1600 is removed. In the “over the wire” approach shown in FIG.16A, to remove the tool and keep the lead 1620 in place, the user needsa relatively long proximal tail on the lead 1620, such that the distalend of the lead 1620 remains in place while the entire tool 1600 isremoved from the patient. In the “rapid-exchange” approach, the lead1620 would exit laterally from the shaft 1606 during removal through thetearable or frangible wall, or slit or channel, reducing the requiredlength of the lead 1620. Concepts and designs of rapid exchangeangioplasty catheters, or from single-operator-exchange biliarycatheters may be used.

FIGS. 17A-17G show several details and variants for another illustrativetunneling tool. FIG. 17A provides a perspective view of an illustrativetunneling tool. The tool 1700 includes a distal tunneling tip 1702,proximal to which an expandable dissecting element is shown at 1704. Ashaft 1706 extends to the dissecting element 1704. A handle is shown at1708 with wings extended therefrom, with the wings aligned relative tothe dissecting element 1704 so that control of the wings 1708 controlsthe plane defined by the width of the dissecting element 1704. Aproximal handle 1710 includes a control knob 1712. Twisting the controlknob 1712 determines the extent to which the dissecting element 1704expands beyond the width of the tunneling tip 1702 and/or shaft 1706.

The tunneling tool 1700 may, in this example, be inserted through aninsertion tube 1720, if desired. The insertion tube 1720 may be asplittable sheath. The additional insertion tube 1720 may be omitted. Aninsertion tube such as that shown at 1720 in FIG. 17A may optionally beused with any of the embodiments shown herein, if desired.

The total length from tip 1702 to handle 1708 may be in the range of,for example, 5 to 18 inches, or more or less, with the total tool lengthbeing from about 10 to 26 inches, or more or less. More desirably, thelength from tip 1702 to handle may be in the range of about 6 to 12inches. Similar lengths may be used in other embodiments shown herein.

FIG. 17B is a detail view of region B in FIG. 17A. It can be seen thatshaft 1706 has a forked distal end to which the tunneling tip 1702 isattached. If desired, a central member may be included to define a lumenthrough the center of shaft 1706 and tip 1702, thought FIG. 17B omitssuch a design. The dissecting element is formed of a pair of wires1704A, 1704B. In some examples, the two sides of the dissecting element1704A, 1704B are designed to symmetrically expand outward as shown. Theoutward bend in this example may be positively induced by advancing acontrol rod 1704 within the shaft 1706 to force the outward bend shown.Alternatively, the outward bend may be caused by a pre-formed shape ofthe wires 1704A, 1704B, with the control rod being retractable from theposition shown in FIG. 17B to pull the wires 1704A, 1704B back undertension to within the shaft 1706.

If desired the wires 1704A, 1704B may be coupled to an electrical sourceor ultrasonic transducer to induce heating or vibration and enhance theability to cut or separate tissue layers. The wires may be springs orspring coils, if desired.

FIGS. 17C and 17D show a further illustration. The tunneling tool 1730is shown here with an outer profile shown in dashed lines at 1732leading to the tip 1734. When the dissecting element 1736 is in theretracted position shown in FIG. 17C, the outer dimension of thedissecting element 1736 is equal to or less than the outer profile 1732,as shown by FIG. 17C. When the dissecting element is expanded, forexample by advancing the control member 1738, the dissecting element1736 outer dimension goes beyond the outer profile 1732 of the tool 1730and tip 1734, as shown in FIG. 17D.

FIG. 17E shown an alternative to FIG. 17A. Here, the tool 1750 includesa tunneling tip 1752 proximal to which is a dissecting element 1754. Aproximal handle is shown with a flattened portion 1756 that has a widththat aligns with the width of the dissecting element 1754. A proximalgrip is shown at 1758 and, in this example a dial 1760 is used with amarker 1762 to determine the extent to which the dissecting element 1754is expanded by the control member (not shown). Turning the dial 1760causes the shape of the dissecting element 1754 to change by one ofrotating or advancing/retracting the control member (not shown). FIG.17F shows another example with a dial 1774 that can be turned located onthe flattened part 1772 of handle 1770, with marker/indicator at 1776.The numbers are shown for illustration; in some examples, the numbersmay indicate a width of the dissecting member 1754, if desired.

FIG. 17G shows some illustrative wire designs that may be used in theconstruction of a dissecting element such as element 1736. A triangularwire 1780, a circular wire 1882, a ribbon wire 1790, and a diamond orsquare wire 1792 may be used. Other shapes may be used as well. Ifdesired, as shown at 1782, the wire may comprise a central core 1784 andwith an outer coating 1786 thereon. Also, as shown at 1792, cuttingelements 1794 in the form of sharpened edges may be provided if desired;alternatively, items 1794 may simply be reinforcement of the edges. Thewire may be formed of any suitable biocompatible material including, forexample, stainless steel, platinum, titanium, or a superelastic alloysuch as nickel-titanium alloy (for example, Nitinol), or others. Thewires 1780, 1782, 1790, 1792 may be solid or hollow, as desired. Suchmaterials and designs may be used as well in the embodiments of FIGS.18A-18B, 19A-19B, 20A-20B, and 21A-21B.

The device of FIGS. 17A-17G may be used in a method such as detailedabove in FIG. 2. For example, the tunneling tip 1702 may be advancedthrough an incision to a desired location, with or without use of aguidewire or stylet. A preliminary tunnel is thus created to a desiredlocation which may be subcutaneous, substernal, or another location towhich lead placement is desired. Next, the dissecting element 1704 isexpanded to expand the tunnel. This may be a single step for dissection,or the dissecting element 1704 may be extended, retracted, repositioned,and extended again, to continue to create a desired space for the lead.Alternatively, the dissecting element 1704 may be expanded and kept inan expanded configuration while it is moved along with the rest of thetool 1700 to create a desired space for the lead. Generally speaking,the aim may be to separate tissue layers as opposed to actually cuttingtissue itself. As before, if desired, a lead having an expandableelectrode may be placed through a lumen (not shown) in tool 1700 andduring tool removal the lead may be kept in place and the electrode thenexpanded into the created space.

FIGS. 18A-18B show another illustrative tunneling tool, in this instancereplacing the spring coils of FIGS. 17A-17G with linkage arrangements.The tool 1800 is shown having a linkage arrangement at 1802, in FIG. 18Ain a retracted configuration as the control rod 1804 is in anon-extended position. When the control rod 1804 is extended, ortwisted, depending on the mechanism used, the linkage 1802 extendsoutward from its retracted position to a dissecting configuration asshown in FIG. 18B. For example, advancing the control rod 1804 may pressforward the linkage 1802 forcing it out of the slits at the end of thetool 1800. In another example, the control rod forces the linkage 1802into the extended position by pulling the distal tip portion 1806 oftool 1800 toward the main shaft 1808. In another example, twisting thecontrol rod, which may be eccentrically shaped near its distal end, toforce the linkage out into an extended configuration. As with otherexamples, a lumen may be provided through the tool 1800 to allow for aguidewire, stylet, or lead to be placed therethrough, and the handle(not shown) may include a guide feature (such as a flattened portion)for alignment control relative to the linkage 1802.

The device of FIGS. 18A-18B may be used in a method such as detailedabove in FIG. 2. For example, the tunneling tip of the distal tipportion 1806 may be advanced through an incision to a desired location,with or without use of a guidewire or stylet. A preliminary tunnel isthus created to a desired location which may be subcutaneous,substernal, or another location to which lead placement is desired.Next, the linkage 1802 is actuated using the control rod 1804 to assumethe dissection configuration shown in FIG. 18B, expanding thepreliminary tunnel. This may be a single step for dissection, or thelinkage 1802 may be retracted and repositioned and extended again tocontinue to create a further desired space for the lead. Alternatively,linkage 1802 may be expanded and kept in an expanded configuration whileit is moved to create a desired space for the lead. Either way, the aimmay be to separate tissue layers as opposed to actually cutting tissueitself. As before, if desired, a lead having an expandable electrode maybe placed through a lumen (not shown) in tool 1800 and during toolremoval the lead may be kept in place and the electrode then expandedinto the created space.

FIGS. 19A-19B show another illustrative tunneling tool. In this example,the tunneling tool 1900 has a tunneling tip at 1902 proximal to which isa spring wire shown at 1904 in phantom in FIG. 19A, and shown in FIG.19B in an extended configuration. The tunneling tool includes a handlehaving a hilt 1910 adjacent to an optional flattened portion 1906 thatmay again serve as a guide for aligning the coil 1904 in a desiredtissue plane. The proximal handle 1908 may, as before, include a portfor access to a thru-lumen for use with a guidewire or stylet or toallow introduction of a lead.

The control mechanism in FIGS. 19A-19B is a sheath 1930 having aproximal handle as shown and a distally extending retraining portionshown at 1932. When the sheath 1930 is placed as shown in FIG. 19A, itcovers and constrains the coil 1904. When moved in the proximaldirection as indicated at 1934, the sheath 1930 releases the spring coil1904 to create a configuration as in FIG. 19B. If desired, a control rodmay be included as well to further control the shape of the spring coil1904. Once the desired tunnel is formed, the sheath 1930 can be advancedover the coil 1904 to constrain it and prepare the tool for removal.

The device of FIGS. 19A-19B may be used in a method such as detailedabove in FIG. 2. For example, the tunneling tip 1902 may be advancedthrough an incision to a desired location, with or without use of aguidewire or stylet. A preliminary tunnel is thus created to a desiredlocation which may be subcutaneous, substernal, or another location towhich lead placement is desired. Next, the sheath 1930 is retracted torelease the spring coil 1904 to assume the dissection configurationshown in FIG. 19B, expanding the preliminary tunnel. This may be asingle step for dissection, or the sheath 1930 may be advanced toconstrain the coil 1904 for repositioning; once repositioned, the sheath1930 may again be retracted to release the spring coil 1904 to create afurther desired space for the lead. Alternatively, the sheath 1930 maybe withdrawn to release the spring coil 1904, and the tool 1900 may bemoved about to create a desired space for the lead. Either way, the aimmay be to separate tissue layers as opposed to actually cutting tissueitself. As before, if desired, a lead having an expandable electrode maybe placed through a lumen (not shown) in tool 1900 and during toolremoval the lead may be kept in place and the electrode then expandedinto the created space.

FIGS. 20A-20B show another illustrative tunneling tool. In this example,the tunneling tool 2000 includes a distal tunneling tip 2002, proximalto which there is a spring coil 2004, shown in phantom in FIG. 20A. Thespring coil 2004 is coupled to a control rod 2008 that is controlledfrom the proximal handle by accessing a switch, slider, tab or lever at2006. Alternatively, a knob or dial may be provided as shown for otherexamples above. The distal end is shown with the spring coil extended inFIG. 20B. It can be seen that the tunneling tip 2002 is near slots 2010that allow the spring coil 2012 to exit the interior of the tool whenthe control rod 2008 is twisted or advanced. In this embodiment, thewire of the spring coil 2012 is preferably somewhat stiff, so that oncethe spring coil 2012 is extended as shown in FIG. 20B, movement of thetunneling tool 2000 causes tissue to be dissected and/or tissue layersto be separated, creating a space for lead implantation. A lumen may beprovided within the tool 2000 for a guidewire, stylet, or lead.

FIGS. 21A-21B show another illustrative tunneling tool. The tool 2100includes a tunneling tip 2102 and a shaft containing a cutting wire2104. The handle 2106 may contain a switch, slider, tab, lever, knob ordial, or other control mechanism, 2108 proximal to which slots 2110 areprovided. As can be see, in this example the cutting wire 2104 includescriss-crossed segments near the distal end of the tool 2100. When thecutting wire 2104 is actuated, it would move as shown in FIG. 21B, withfree ends 2112 exiting via slots 2110 from within the tool 2100, nearand proximal to the distal dissecting tip 2102. In this embodiment, thecutting wire 2104 is preferably somewhat stiff, so that once extended asshown in FIG. 21B, movement of the tunneling tool 2100 causes tissue tobe dissected and/or tissue layers to be separated, creating a space forlead implantation. Again, a lumen may be provided within the tool 2100for a guidewire, stylet, or lead.

The devices of FIGS. 20A-20B and 21A-21B may be used in a method such asdetailed above in FIG. 2. For example, the tunneling tip 2002 or 2102may be advanced through an incision to a desired location, with orwithout use of a guidewire or stylet. A preliminary tunnel is thuscreated to a desired location which may be subcutaneous, substernal, oranother location to which lead placement is desired. Next, the springcoil 2004 or cutting wire 2104 is extended out of slots 2010/2110 toassume the dissection configuration shown in FIGS. 20B/21B. The tools2000, 2100 are then moved by advancing or withdrawing them to dissecttissue or separate tissue layers. The proximal ends of each tool 2000,2100 may include flattened or other portions for alignment to thedesired tissue plane, as in earlier examples. The aim may be to separatetissue layers as opposed to actually cutting tissue itself. As before,if desired, a lead having an expandable electrode may be placed througha lumen (not shown) in tool 2000/2100 and during tool removal the leadmay be kept in place and the electrode then expanded into the createdspace.

Non-Limiting Examples

In a first example an implantable defibrillator may comprise a canisterhousing a source of electrical energy, a capacitor, and operationalcircuitry that senses heart rhythms and an electrode and lead assembly.The electrode and lead assembly may comprise a lead, at least onesensing electrode, and at least one shocking electrode. The at least oneshocking electrode may extend over a length in the range of 50 to 110millimeters and a width in the range of 1 to 40 millimeters.

Alternatively or additionally to any of the examples above, in a secondexample, the at least one shocking electrode may comprise a coilelectrode having a generally flattened oval shape.

Alternatively or additionally to any of the examples above, in a thirdexample, the coil electrode may have a closed pitch.

Alternatively or additionally to any of the examples above, in a fourthexample, the at least one shocking electrode may comprise a plurality ofcoil electrodes.

Alternatively or additionally to any of the examples above, in a fifthexample, the plurality of coil electrodes may be configured to beactuated between a delivery configuration and an implantedconfiguration.

Alternatively or additionally to any of the examples above, in a sixthexample, the implanted configuration may have a larger width than thedelivery configuration.

Alternatively or additionally to any of the examples above, in a seventhexample, the implantable defibrillator may further comprise a push-pullmechanism configured to move the plurality of electrodes between thedelivery configuration and the implanted configuration.

Alternatively or additionally to any of the examples above, in an eighthexample, the shocking electrode may comprise a first coil electrodehaving one or more oscillations about a longitudinal axis of the lead,each oscillation having at least one peak and valley.

Alternatively or additionally to any of the examples above, in a ninthexample, the shocking electrode may comprise a first coil electrodewound into a helical configuration.

Alternatively or additionally to any of the examples above, in a tenthexample, the implantable defibrillator may further comprise a secondcoil electrode having one or more oscillations, each oscillation havingat least one peak and valley, wherein the first and second coilelectrodes are coiled in directions such that a valley of the first coilelectrode may be positioned adjacent to a peak of the second coilelectrode.

Alternatively or additionally to any of the examples above, in aneleventh example, the implantable defibrillator may further comprise asecond coil wound into a helical configuration, wherein the first andsecond coil electrodes are wound in opposite directions.

Alternatively or additionally to any of the examples above, in a twelfthexample, the shocking electrode may comprise a woven electricallyconductive mesh at least partially embedded in a silicone carrier.

Alternatively or additionally to any of the examples above, in athirteenth example, the shocking electrode may comprise a printedcircuit disposed on a liquid crystal polymer.

Alternatively or additionally to any of the examples above, in afourteenth example, one of the at least one sensing electrode and the atleast one shocking electrode may further comprise a high capacitivecoating.

Alternatively or additionally to any of the examples above, in afifteenth example, the implantable defibrillator may further comprise amembrane disposed over at least a portion of the lead and electrodeassembly.

Alternatively or additionally to any of the examples above, in asixteenth example, the at least one shocking electrode may extend over alength in the range of 60 to 100 millimeters.

Alternatively or additionally to any of the examples above, in aseventeenth example, the at least one shocking electrode may extend overa length in the range of 70 to 90 millimeters.

Alternatively or additionally to any of the examples above, in aeighteenth example, the at least one shocking electrode may have a widthin the range of 10 to 30 millimeters.

Alternatively or additionally to any of the examples above, in anineteenth example, the at least one shocking electrode may have a widthin the range of 15 to 25 millimeters.

Alternatively or additionally to any of the examples above, in atwentieth example, the lead may be configured for subcutaneousimplantation and the canister houses operational circuitry configuredfor use as a subcutaneous-only defibrillator.

In a twenty first example, a method of implanting a defibrillator as inany of examples one through twenty may comprise implanting the canisterin the left axillary region of a patient, implanting the leadsubcutaneously over the ribcage of the patient and beneath the skin, andcoupling the lead to the canister.

Alternatively or additionally to any of the examples above, in a twentysecond example, the lead may be configured for implantation beneath thesternum of a patient and the canister houses operational circuitryconfigured for use as a substernal defibrillator.

In a twenty third example, a method for implanting a defibrillator as inany of example one through nineteen or twenty two may compriseimplanting the canister in the left axillary region of a patient,implanting the lead substernally behind the sternum of the patient andoutside of the heart and pericardium, and coupling the lead to thecanister.

In a twenty fourth example, an implantable defibrillator may comprise acanister housing a source of electrical energy, a capacitor, andoperational circuitry that senses heart rhythms and an electrode andlead assembly. The electrode and lead assembly may comprise a lead, atleast one sensing electrode, and a coil electrode comprising a helicallywound element and having a generally oval cross-sectional shape. Thecoil electrode may extend over a length in the range of 50 to 110millimeters and a width in the range of 1 to 40 millimeters.

Alternatively or additionally to any of the examples above, in a twentyfifth example, the coil electrode may have a closed pitch.

Alternatively or additionally to any of the examples above, in a twentysixth example, the coil electrode may have an open pitch.

Alternatively or additionally to any of the examples above, in a twentyseventh example, the coil electrode may be disposed over a portion ofthe lead.

Alternatively or additionally to any of the examples above, in a twentyeighth example, the at least one sensing electrode may comprise aproximal sensing electrode positioned proximal to the coil electrode anda distal sensing electrode positioned distal to the coil electrode.

Alternatively or additionally to any of the examples above, in a twentyninth example, one of the at least one sensing electrode and the coilelectrode may further comprise a high capacitive coating.

Alternatively or additionally to any of the examples above, in athirtieth example, the implantable defibrillator may further comprise amembrane disposed over at least a portion of the lead and electrodeassembly.

Alternatively or additionally to any of the examples above, in a thirtyfirst example, the coil electrode may extend over a length in the rangeof 60 to 100 millimeters.

Alternatively or additionally to any of the examples above, in a thirtysecond example, the coil electrode may extend over a length in the rangeof 70 to 90 millimeters. Alternatively or additionally to any of theexamples above, in a thirty third example, the coil electrode may have awidth in the range of 10 to 30 millimeters.

Alternatively or additionally to any of the examples above, in a thirtyfourth example, the coil electrode may have a width in the range of 15to 25 millimeters.

In a thirty fifth example, an implantable defibrillator may comprise acanister housing a source of electrical energy, a capacitor, andoperational circuitry that senses heart rhythms and an electrode andlead assembly. The electrode and lead assembly may comprise a lead, atleast one sensing electrode, and a shocking electrode. The shockingelectrode may comprise a first electrode and a second electrode eachhaving a proximal end and a distal end, wherein the first electrode andthe second electrode are each coupled to the lead at their proximal anddistal ends.

Alternatively or additionally to any of the examples above, in a thirtysixth example, the implantable defibrillator may further comprise anactuation mechanism.

Alternatively or additionally to any of the examples above, in a thirtyseventh example, the actuation mechanism may be a push-pull member.

Alternatively or additionally to any of the examples above, in a thirtyeighth example, the shocking electrode may be configured to be actuatedbetween a delivery configuration and an implanted configuration.

Alternatively or additionally to any of the examples above, in a thirtyninth example, the implanted configuration may have a larger width thana width of the delivery configuration.

Alternatively or additionally to any of the examples above, in afortieth example, at least one of the first and second electrodes maycomprise an electrically conductive strut.

Alternatively or additionally to any of the examples above, in a fortyfirst example, at least one of the first and second electrodes maycomprise a helically wound coil electrode.

Alternatively or additionally to any of the examples above, in a fortysecond example, the first and second electrodes may be axially spacedfrom a longitudinal axis of the lead.

Alternatively or additionally to any of the examples above, in a fortythird example, the at least one sensing electrode may comprise aproximal sensing electrode positioned proximal to the shocking electrodeand a distal sensing electrode positioned distal to the shockingelectrode.

Alternatively or additionally to any of the examples above, in a fortyfourth example, one of the at least one sensing electrode and theshocking electrode may further comprise a high capacitive coating.

Alternatively or additionally to any of the examples above, in a fortyfifth example, the implantable defibrillator may further comprise amembrane disposed over at least a portion of the lead and electrodeassembly.

Alternatively or additionally to any of the examples above, in a fortysixth example, when in the implanted configuration, the shockingelectrode may extend over a length in the range of 50 to 110millimeters.

Alternatively or additionally to any of the examples above, in a fortyseventh example, when in the implanted configuration, the shockingelectrode may extend over a length in the range of 60 to 100millimeters.

Alternatively or additionally to any of the examples above, in a fortyeighth example, when in the implanted configuration, the shockingelectrode may extend over a length in the range of 70 to 90 millimeters.

Alternatively or additionally to any of the examples above, in a fortyninth example, when in the implanted configuration, the shockingelectrode may have a width in the range of 1 to 40 millimeters.

Alternatively or additionally to any of the examples above, in afiftieth example, when in the implanted configuration, the shockingelectrode may have a width in the range of 10 to 30 millimeters.

Alternatively or additionally to any of the examples above, in a fiftyfirst example, when in the implanted configuration, the shockingelectrode may have a width in the range of 15 to 25 millimeters.

In a fifty second example, an implantable defibrillator may comprise acanister housing a source of electrical energy, a capacitor, andoperational circuitry that senses heart rhythms and an electrode andlead assembly. The electrode and lead assembly may comprise a leadhaving a longitudinal axis, at least one sensing electrode, and ashocking electrode. The shocking electrode may comprise a first coilelectrode having a curved configuration including a first curved regionthat may extend axially away from the longitudinal axis of the lead in afirst direction and a second curved region that may extend axially awayfrom the longitudinal axis of the lead in a second direction oppositefrom the first. The shocking electrode may extend over a length in therange of 50 to 110 millimeters and a width in the range of 1 to 40millimeters.

Alternatively or additionally to any of the examples above, in a fiftythird example, the first curved region and the second curved region ofthe first coil electrode form at least a partial oscillation about thelongitudinal axis of the lead.

Alternatively or additionally to any of the examples above, in a fiftyfourth example, the first coil electrode may further comprise additionalcurved regions to form one or more oscillations about the longitudinalaxis of the lead.

Alternatively or additionally to any of the examples above, in a fiftyfifth example, the shocking electrode may further comprise a second coilelectrode, the second coil electrode having a having a curvedconfiguration including a first curved region that may extend axiallyaway from the longitudinal axis of the lead in the second direction anda second curved region that may extend axially away from thelongitudinal axis of the lead in the first direction opposite.

Alternatively or additionally to any of the examples above, in a fiftysixth example, the first coil electrode and the second coil electrodemay cross at one or more cross points.

Alternatively or additionally to any of the examples above, in a fiftyseventh example, the first coil electrode may be configured to bestraightened into a straightened configuration for delivery.

Alternatively or additionally to any of the examples above, in a fiftyeighth example, the second coil electrode may be configured to bestraightened into a straightened configuration for delivery.

Alternatively or additionally to any of the examples above, in a fiftyninth example, when in the straightened configuration, the first coilelectrode may have a reduced profile relative to the curvedconfiguration.

Alternatively or additionally to any of the examples above, in asixtieth example, when in the straightened configuration, the secondcoil electrode may have a reduced profile relative to the curvedconfiguration.

Alternatively or additionally to any of the examples above, in a sixtyfirst example, the at least one sensing electrode may comprise aproximal sensing electrode positioned proximal to the shocking electrodeand a distal sensing electrode positioned distal to the shockingelectrode.

Alternatively or additionally to any of the examples above, in a sixtysecond example, at least a portion of the lead and electrode assemblymay further comprise a high capacitive coating.

Alternatively or additionally to any of the examples above, in a sixtythird example, the implantable defibrillator may further comprise amembrane disposed over at least a portion of the lead and electrodeassembly.

Alternatively or additionally to any of the examples above, in a sixtyfourth example, the shocking electrode may extend over a length in therange of 60 to 100 millimeters.

Alternatively or additionally to any of the examples above, in a sixtyfifth example, the shocking electrode may extend over a length in therange of 70 to 90 millimeters.

Alternatively or additionally to any of the examples above, in a sixtysixth example, the shocking electrode may have a width in the range of10 to 30 millimeters.

Alternatively or additionally to any of the examples above, in a sixtyseventh example, the shocking electrode may have a width in the range of15 to 25 millimeters.

In a sixty eighth example an implantable defibrillator may comprise acanister housing a source of electrical energy, a capacitor, andoperational circuitry that senses heart rhythms and an electrode andlead assembly. The electrode and lead assembly may comprise a leadhaving a longitudinal axis, at least one sensing electrode, and ashocking electrode. The shocking electrode may comprise a first coilelectrode may comprise a helically wound element, the first coilelectrode wound into a first helical configuration about thelongitudinal axis of the lead. The shocking electrode may extend over alength in the range of 50 to 110 millimeters and a width in the range of1 to 40 millimeters.

Alternatively or additionally to any of the examples above, in a sixtyninth example, the shocking electrode may further comprise a second coilelectrode may comprise a helically wound element, the second coilelectrode wound into a second helical configuration about thelongitudinal axis of the lead, the second helical configurationextending in a rotational direction opposite the first helicalconfiguration.

Alternatively or additionally to any of the examples above, in aseventieth example, the first coil electrode and the second coilelectrode may cross at one or more cross points.

Alternatively or additionally to any of the examples above, in a seventyfirst example, the first coil electrode may be configured to bestraightened into a straightened configuration for delivery.

Alternatively or additionally to any of the examples above, in a seventysecond example, the second coil electrode may be configured to bestraightened into a straightened configuration for delivery.

Alternatively or additionally to any of the examples above, in a seventythird example, when in the straightened configuration, the first coilelectrode may have a reduced profile relative to the curvedconfiguration.

Alternatively or additionally to any of the examples above, in a seventyfourth example, when in the straightened configuration, the second coilelectrode may have a reduced profile relative to the curvedconfiguration.

Alternatively or additionally to any of the examples above, in a seventyfifth example, the at least one sensing electrode may comprise aproximal sensing electrode positioned proximal to the shocking electrodeand a distal sensing electrode positioned distal to the shockingelectrode.

Alternatively or additionally to any of the examples above, in a seventysixth example, at least a portion of the lead and electrode assembly mayfurther comprise a high capacitive coating.

Alternatively or additionally to any of the examples above, in a seventyseventh example, the implantable defibrillator may further comprise amembrane disposed over at least a portion of the lead and electrodeassembly.

Alternatively or additionally to any of the examples above, in a seventyeighth example, the shocking electrode may extend over a length in therange of 60 to 100 millimeters.

Alternatively or additionally to any of the examples above, in a seventyninth example, the shocking electrode may extend over a length in therange of 70 to 90 millimeters.

Alternatively or additionally to any of the examples above, in aneightieth example, the shocking electrode may have a width in the rangeof 10 to 30 millimeters.

Alternatively or additionally to any of the examples above, in an eightyfirst example, the shocking electrode may have a width in the range of15 to 25 millimeters.

In an eighty second example, an implantable defibrillator may comprise acanister housing a source of electrical energy, a capacitor, andoperational circuitry that senses heart rhythms and an electrode andlead assembly. The electrode and lead assembly may comprise a leadhaving a longitudinal axis, at least one sensing electrode, and ashocking electrode. The shocking electrode may comprise an electricallyconductive material embedded in a silicone carrier. The shockingelectrode may extend over a length in the range of 50 to 110 millimetersand a width in the range of 1 to 40 millimeters.

Alternatively or additionally to any of the examples above, in an eightythird example, the electrically conductive material may comprise one ormore woven filaments.

Alternatively or additionally to any of the examples above, in an eightyforth example, the electrically conductive material may comprise one ormore braided filaments.

Alternatively or additionally to any of the examples above, in an eightyfifth example, the electrically conductive material may comprise a lasercut pattern.

In an eighty sixth example, an implantable defibrillator may comprise acanister housing a source of electrical energy, a capacitor, andoperational circuitry that senses heart rhythms and an electrode andlead assembly. The electrode and lead assembly may comprise a leadhaving a longitudinal axis, at least one sensing electrode, and ashocking electrode. The shocking electrode may comprise a printedcircuit disposed on a liquid crystal polymer. The shocking electrode mayextend over a length in the range of 50 to 110 millimeters and a widthin the range of 1 to 40 millimeters.

Alternatively or additionally to any of the examples above, in an eightyseventh example, the printed circuit may comprise one or more traces.

Alternatively or additionally to any of the examples above, in an eightyeighth example, the one or more traces may be positioned in a windingconfiguration on the liquid crystal polymer.

Alternatively or additionally to any of the examples above, in an eightyninth example, the one or more traces may fan out from a central region.

Alternatively or additionally to any of the examples above, in aninetieth example, the printed circuit may comprise one or moreelectrode pads.

Alternatively or additionally to any of the examples above, in a ninetyfirst example, the shocking electrode may have a generally oval shapedouter perimeter.

Alternatively or additionally to any of the examples above, in a ninetysecond example, the shocking electrode may have a generally rectangularshaped outer perimeter.

Alternatively or additionally to any of the examples above, in a ninetythird example, the shocking electrode may be configured to be rolled fordelivery.

Alternatively or additionally to any of the examples above, in a ninetyfourth example, the at least one sensing electrode may comprise aproximal sensing electrode positioned proximal to the shocking electrodeand a distal sensing electrode positioned distal to the shockingelectrode.

Alternatively or additionally to any of the examples above, in a ninetyfifth example, at least a portion of the lead and electrode assembly mayfurther comprise a high capacitive coating.

Alternatively or additionally to any of the examples above, in a ninetysixth example, the implantable defibrillator may further comprise amembrane disposed over at least a portion of the lead and electrodeassembly.

Alternatively or additionally to any of the examples above, in a ninetyseventh example, the shocking electrode may extend over a length in therange of 60 to 100 millimeters.

Alternatively or additionally to any of the examples above, in a ninetyeighth example, the shocking electrode may extend over a length in therange of 70 to 90 millimeters.

Alternatively or additionally to any of the examples above, in a ninetyninth example, the shocking electrode may have a width in the range of10 to 30 millimeters.

Alternatively or additionally to any of the examples above, in a onehundredth example, the shocking electrode may have a width in the rangeof 15 to 25 millimeters.

Alternatively or additionally to any of the examples above, in a onehundred and first example, the lead may be configured for subcutaneousimplantation and the canister houses operational circuitry configuredfor use as a subcutaneous-only defibrillator.

In a one hundred and second example, a method for implanting adefibrillator as in any of examples twenty four through one hundred andone may comprise implanting the canister in the left axillary region ofa patient, implanting the lead subcutaneously over the ribcage of thepatient and beneath the skin, and coupling the lead to the canister.

Alternatively or additionally to any of the examples above, in a onehundred and third example, the lead may be configured for implantationbeneath the sternum of a patient and the canister houses operationalcircuitry configured for use as a substernal defibrillator.

In a one hundred and fourth example, a method for implanting adefibrillator as in any of examples twenty four through one hundred andone or one hundred and three may comprise implanting the canister in theleft axillary region of a patient, implanting the lead substernallybehind the sternum of the patient and outside of the heart andpericardium, and coupling the lead to the canister.

Each of these non-limiting examples can stand on its own, or can becombined in various permutations or combinations with one or more of theother examples.

The materials that can be used for the various components of the leadand electrode assembly, delivery tools, and/or other devices disclosedherein may include those commonly associated with medical devices. Forsimplicity purposes, the following discussion makes reference toaccessory devices and their related components. However, this is notintended to limit the devices and methods described herein, as thediscussion may be applied to other similar devices, tubular membersand/or components of tubular members or devices disclosed herein.

The various components of the devices/systems disclosed herein mayinclude a metal, metal alloy, polymer (some examples of which aredisclosed below), a metal-polymer composite, ceramics, combinationsthereof, and the like, or other suitable material. Some examples ofsuitable metals and metal alloys include stainless steel, such as 304V,304L, and 316LV stainless steel; mild steel; nickel-titanium alloy suchas linear-elastic and/or super-elastic nitinol; other nickel alloys suchas nickel-chromium-molybdenum alloys (e.g., UNS: N06625 such as INCONEL®625, UNS: N06022 such as HASTELLOY® C-22®, UNS: N10276 such asHASTELLOY® C276®, other HASTELLOY® alloys, and the like), nickel-copperalloys (e.g., UNS: N04400 such as MONEL® 400, NICKELVAC® 400, NICORROS®400, and the like), nickel-cobalt-chromium-molybdenum alloys (e.g., UNS:R30035 such as MP35-N® and the like), nickel-molybdenum alloys (e.g.,UNS: N10665 such as HASTELLOY® ALLOY B2®), other nickel-chromium alloys,other nickel-molybdenum alloys, other nickel-cobalt alloys, othernickel-iron alloys, other nickel-copper alloys, other nickel-tungsten ortungsten alloys, and the like; cobalt-chromium alloys;cobalt-chromium-molybdenum alloys (e.g., UNS: R30003 such as ELGILOY®,PHYNOX®, and the like); platinum enriched stainless steel; titanium;combinations thereof; and the like; or any other suitable material.

Some examples of suitable polymers may include polytetrafluoroethylene(PTFE), ethylene tetrafluoroethylene (ETFE), fluorinated ethylenepropylene (FEP), polyoxymethylene (POM, for example, DELRIN® availablefrom DuPont), polyether block ester, polyurethane (for example,Polyurethane 85A), polypropylene (PP), polyvinylchloride (PVC),polyether-ester (for example, ARNITEL® available from DSM EngineeringPlastics), ether or ester based copolymers (for example,butylene/poly(alkylene ether) phthalate and/or other polyesterelastomers such as HYTREL® available from DuPont), polyamide (forexample, DURETHAN® available from Bayer or CRISTAMID® available from ElfAtochem), elastomeric polyamides, block polyamide/ethers, polyetherblock amide (PEBA, for example available under the trade name PEBAX®),ethylene vinyl acetate copolymers (EVA), silicones, polyethylene (PE),Marlex high-density polyethylene, Marlex low-density polyethylene,linear low density polyethylene (for example REXELL®), polyester,polybutylene terephthalate (PBT), polyethylene terephthalate (PET),polytrimethylene terephthalate, polyethylene naphthalate (PEN),polyetheretherketone (PEEK), polyimide (PI), polyetherimide (PEI),polyphenylene sulfide (PPS), polyphenylene oxide (PPO), polyparaphenylene terephthalamide (for example, KEVLAR®), polysulfone,nylon, nylon-12 (such as GRILAMID® available from EMS American Grilon),perfluoro(propyl vinyl ether) (PFA), ethylene vinyl alcohol, polyolefin,polystyrene, epoxy, polyvinylidene chloride (PVdC),poly(styrene-b-isobutylene-b-styrene) (for example, SIBS and/or SIBS A),polycarbonates, ionomers, biocompatible polymers, other suitablematerials, or mixtures, combinations, copolymers thereof, polymer/metalcomposites, and the like. In some embodiments the sheath can be blendedwith a liquid crystal polymer (LCP). For example, the mixture cancontain up to about 6 percent LCP.

In at least some embodiments, portions or all of the accessory devicesand their related components may be doped with, made of, or otherwiseinclude a radiopaque material. Radiopaque materials are understood to bematerials capable of producing a relatively bright image on afluoroscopy screen or another imaging technique during a medicalprocedure. This relatively bright image aids the user of the accessorydevices and their related components in determining its location. Someexamples of radiopaque materials can include, but are not limited to,gold, platinum, palladium, tantalum, tungsten alloy, polymer materialloaded with a radiopaque filler, and the like. Additionally, otherradiopaque marker bands and/or coils may also be incorporated into thedesign of the accessory devices and their related components to achievethe same result.

The above detailed description includes references to the accompanyingdrawings, which form a part of the detailed description. The drawingsshow, by way of illustration, specific embodiments in which theinvention can be practiced. These embodiments are also referred toherein as “examples.” Such examples can include elements in addition tothose shown or described. However, the present inventors alsocontemplate examples in which only those elements shown or described areprovided. Moreover, the present inventors also contemplate examplesusing any combination or permutation of those elements shown ordescribed (or one or more aspects thereof), either with respect to aparticular example (or one or more aspects thereof), or with respect toother examples (or one or more aspects thereof) shown or describedherein.

In the event of inconsistent usages between this document and anydocuments so incorporated by reference, the usage in this documentcontrols. In this document, the terms “a” or “an” are used, as is commonin patent documents, to include one or more than one, independent of anyother instances or usages of “at least one” or “one or more.” Moreover,in the following claims, the terms “first,” “second,” and “third,” etc.are used merely as labels, and are not intended to impose numericalrequirements on their objects.

Method examples described herein can be machine or computer-implementedat least in part. Some examples can include a computer-readable mediumor machine-readable medium encoded with instructions operable toconfigure an electronic device to perform methods as described in theabove examples. An implementation of such methods can include code, suchas microcode, assembly language code, a higher-level language code, orthe like. Such code can include computer readable instructions forperforming various methods. The code may form portions of computerprogram products. Further, in an example, the code can be tangiblystored on one or more volatile, non-transitory, or non-volatile tangiblecomputer-readable media, such as during execution or at other times.Examples of these tangible computer-readable media can include, but arenot limited to, hard disks, removable magnetic or optical disks,magnetic cassettes, memory cards or sticks, random access memories(RAMs), read only memories (ROMs), and the like.

The above description is intended to be illustrative, and notrestrictive. For example, the above-described examples (or one or moreaspects thereof) may be used in combination with each other. Otherembodiments can be used, such as by one of ordinary skill in the artupon reviewing the above description.

The Abstract is provided to comply with 37 C.F.R. § 1.72(b), to allowthe reader to quickly ascertain the nature of the technical disclosure.It is submitted with the understanding that it will not be used tointerpret or limit the scope or meaning of the claims.

Also, in the above Detailed Description, various features may be groupedtogether to streamline the disclosure. This should not be interpreted asintending that an unclaimed disclosed feature is essential to any claim.Rather, inventive subject matter may lie in less than all features of aparticular disclosed embodiment. Thus, the following claims are herebyincorporated into the Detailed Description as examples or embodiments,with each claim standing on its own as a separate embodiment, and it iscontemplated that such embodiments can be combined with each other invarious combinations or permutations. The scope of the invention shouldbe determined with reference to the appended claims, along with the fullscope of equivalents to which such claims are entitled.

What is claimed is:
 1. An implantable defibrillator comprising: acanister housing a source of electrical energy, a capacitor, andoperational circuitry that senses heart rhythms; and an electrode andlead assembly, the electrode and lead assembly comprising: a lead with aproximal end adapted for attachment to the canister and a distal end; atleast one sensing electrode on the lead; and at least one shockingelectrode on the lead; wherein the at least one shocking electrodeextends over a length in the range of 50 to 110 millimeters and a widthin the range of 5 to 35 millimeters; and wherein the at least onesensing electrode is distal to the at least one shocking electrode. 2.The implantable defibrillator of claim 1, wherein the shocking electrodeextends over a length in the range of 70 to 90 millimeters.
 3. Theimplantable defibrillator of claim 1, wherein the shocking electrode hasa width in the range of 15 to 25 millimeters.
 4. The implantabledefibrillator of claim 1, wherein the at least one shocking electrodecomprises a solid surface electrode having a generally flattened ovalshape.
 5. The implantable defibrillator of claim 4, wherein the solidsurface electrode comprises a solid unitary metallic structure.
 6. Theimplantable defibrillator of claim 4, wherein the solid surfaceelectrode comprises a metallic shell disposed over a polymericstructure.
 7. The implantable defibrillator of claim 1, wherein theshocking electrode comprises an electrically conductive material atleast partially embedded in a silicone carrier.
 8. The implantabledefibrillator of claim 7, wherein the electrically conductive materialcomprises one or more woven filaments.
 9. The implantable defibrillatorof 7, wherein the electrically conductive material comprises one or morebraided filaments.
 10. The implantable defibrillator of claim 7, whereinthe electrically conductive material comprises a laser cut pattern. 11.The implantable defibrillator of claim 7, wherein the shocking electrodeis configured to be collapsible.
 12. The implantable defibrillator ofclaim 7, wherein the shocking electrode has a generally rectangularperipheral shape.
 13. The implantable defibrillator of claim 1, furthercomprising a permeable membrane positioned on the shocking electrode.14. An implantable defibrillator comprising: a canister housing a sourceof electrical energy, a capacitor, and operational circuitry that sensesheart rhythms; and an electrode and lead assembly, the electrode andlead assembly comprising: a lead with a proximal end adapted forattachment to the canister and a distal end; at least one sensingelectrode on the lead; and at least one shocking electrode comprising asolid surface electrode having a generally flattened oval shape on thelead; wherein the at least one shocking electrode extends over a lengthin the range of 60 to 100 millimeters and a width in the range of 10 to30 millimeters; and wherein the at least one sensing electrode is distalto the at least one shocking electrode.
 15. The implantabledefibrillator of claim 14, wherein the solid surface electrode comprisesa solid unitary metallic structure.
 16. The implantable defibrillator ofclaim 14, wherein the solid surface electrode comprises a metallic shelldisposed over a polymeric structure.
 17. An implantable defibrillatorcomprising: a canister housing a source of electrical energy, acapacitor, and operational circuitry that senses heart rhythms; and anelectrode and lead assembly, the electrode and lead assembly comprising:a lead with a proximal end adapted for attachment to the canister and adistal end; at least one sensing electrode on the lead; and at least oneshocking electrode comprising an electrically conductive material atleast partially embedded in a silicone carrier making up a portion ofthe lead; wherein the at least one shocking electrode extends over alength in the range of 60 to 100 millimeters and a width in the range of10 to 30 millimeters; and wherein the at least one sensing electrode isdistal to the at least one shocking electrode.
 18. The implantabledefibrillator of claim 17, wherein the electrically conductive materialcomprises one or more woven filaments.
 19. The implantable defibrillatorof 17, wherein the electrically conductive material comprises one ormore braided filaments.
 20. The implantable defibrillator of claim 17,wherein the electrically conductive material comprises a laser cutpattern.